The following is adapted from my book: Chapter B / Honeymoon Learnings: Anger and Perception, Concussion Is Brain Injury: Treating the Neurons and Me.
Brain Injury Anger
Are adults likely to exhibit dramatic behavioural changes simply because they feel like it? Would you suddenly choose to go from being a friendly, hard worker to wooden and humourless with angry, scary outbursts?
I learned in February 2010, no training manual, no cohesive approach, no general knowledge exists on what brain injury anger is and how to deal with it. This is why most of us with brain injury are shunted into useless behavioural forms of “treatment,” which leads to regular failure in trying to control anger. You cannot control what is broken. Regular anger-management training doesn’t work. It’s inappropriate for brain injury anger. This is why brain injury anger destroys relationships, costs jobs, and leads to permanent self-image of being unlikeable and a failure.
Researchers have failed us, for they’ve had since the famous case of Phineas Gage† in the late 1800s to study anger unique to brain injury that arises out of neurophysiological damage. And specialists have failed us, for they’ve not learned from Phineas Gage that it’s a direct result of injury not behavioural or psychological change. They’ve had well over a century to learn how to distinguish between brain injury anger and other forms of anger and to respond appropriately and differently to them. And that perhaps moral anger increases in people with brain injury because of being judged so often and because the cause of the injury often arises out of injustice like a car crash perpetrated by another sober driver or a vicious opponent in hockey.
Anger Is Like…
Brain-injury anger is like a wild animal that leaps into your brain screaming and gnashing its teeth, hurtling you into a freakishly strong fight response that shocks you as much as it does others. It can manifest from simple bellowing all the way up to yelling while hurling an offending object. Ignorance of how this anger is different can inadvertently escalate it.
There are several issues with brain-injury anger:
- Understanding that it’s a physiological process impervious to behavioural therapies
- Understanding its locus in the brain
- Understanding that the affected neurons and neural networks need treatment
- Understanding that anger wakes up the injured brain and allows you to think and respond rather than sitting like a silent lump unable to express what’s in your head
- Understanding that suppressed anger is the kind of anger that drains and teaching a person to shut down their anger instead of expressing and healing it contributes to their fatigue
- Understanding that sensory overload is like nails on chalkboard, which creates irritability and that irritability either expresses itself as running away, avoiding, or, if unable to do so, yelling at the offending cause
- Understanding that everyone, from family to psychiatrists, not just the behavioural therapist, must learn how to de-escalate it.
Acupuncture, brain biofeedback, and audiovisual entrainment (AVE), treatments that I underwent for other brain injury symptoms, had this rather nice effect of reducing my irritability from sensory overload and healing my brain injury anger. I discovered that a combination of avoiding my severest triggers, my hypothalamus fix (Chapter Q*), and gamma brainwave enhancement (Chapter R*) led to my brain-injury anger becoming rare. Unfortunately, continual judgement combined with effective treatments that allowed me to recently gain some control over my emotions and anger, have taught me to suppress my moral anger, and so it both drains me and, like many with suppressed anger, emerge unexpectedly.
Perhaps the effect of my hypothalamus fix on my brain injury anger gives us a clue to its origin. The brain has an autonomic nervous system comprising the sympathetic and parasympathetic arms. For the purpose of initial theorizing, I’ll talk only about the sympathetic system:
Scholar and neuroscientist Andrew Newberg in his series on the Spiritual Brain, said: “That’s exactly what [the sympathetic system] does. It arouses us. It turns us on. It’s the on switch of the body. . . . It turns on when something of motivational importance happens in our environment that we need to react to. It happens automatically . . . before you even start to think about what’s going on.” (bolding mine)Great Courses, The Spiritual Brain, Lecture 3: Brain Function and Religion
The Limbic system of the brain controls the autonomic nervous system.
Three parts of the Limbic system you may be familiar with: the amygdala, hippocampus, and hypothalamus. The Limbic system seems to be the primary emotional controller. The amygdala turns on when something of emotional importance occurs, whether something fearful or happy. The hippocampus regulates emotional responses to keep us from being extremely quiescent or extremely emotional. It also writes memories. It sits behind the amygdala, suggesting that only when the amygdala turns on does the hippocampus write the memory down so we’ll remember the emotionally important event, whether we experienced the joy of a special dinner or the awfulness of a friend betraying us. The hypothalamus controls the autonomic system. It turns on the sympathetic arm of the system or the parasympathetic arm. Most of the time, only one of these arms are on at any given moment.
Effect of Hypothalamus Damage?
What happens if the hypothalamus is damaged? We know from my single-subject study of the hypothalamus fix and from numerous reports of hormonal disruption after brain injury that although this tiny part of the brain is deep inside it, seemingly protected from disruptive forces, it can be damaged. Let’s say it is. Then an undamaged amygdala can turn on when someone attacks you; but a damaged hypothalamus cannot respond appropriately or at all. Perhaps the lack of response leads the amygdala to increasing its alarm until it finally “wakes up” the hypothalamus. But at that point, the excitatory impulses from the amygdala are at the level they would be at if something of extreme danger was attacking you; thus the hypothalamus would turn the arousal system on at that level.
Perhaps brain injury anger is the fight response.
Concurrent Effect of Hippocampus Damage?
What if, at the same time, a damaged hippocampus cannot regulate emotions such that you exist in two extremes — sitting like a lump or screaming like a banshee — then it won’t calm the amygdala’s increasing clarion call, which it would under normal circumstances where immediate mortal danger wasn’t at hand. That could be a contributing reason for the hypothalamus to arouse you from zero to overload instantly. That’s how brain injury anger manifests: it goes from non-existent to full on instantly. And it turns off that way, too: from full on to non-existent in an instant. It’s weird and confusing, although I was relieved that it simply switched off instantly and so completely that no residual anger remained.
Since the arousal system energizes you, this could account for why brain injury anger energizes.
“the hypothalamus regulates the stress reaction. When stress increases, it releases glucose (sugar) from a compound called “glycogen” in your liver to provide the body with energy.”The Hypothalamus and Brain Injury, 12 October 2010, jeejeebhoy.ca (See Concussion Is Brain Injury: Treating the Neurons and Me for updated and fuller explanation of my hypothalamus fix.)
The increased energy, the release of glucose to an injured brain that requires more energy input than a healthy brain, and all the other effects of being aroused, may be why brain injury anger leads to being able to think and express significantly better than when you’re in your “normal” injured state. And since the normal state of brain injury is intense fatigue, the return to “normal” won’t feel like you’re drained.
Being misunderstood, disrespected, put down, acted thoughtlessly toward, being overwhelmed, being refused to be accommodated, inaccessible public transit and city systems, abandoned, and betrayed creates moral anger. A psychiatrist or psychologist familiar with brain injury, willing to keep up with the latest understandings of brain injury and how to treat it, helps with extensive talk, psychodynamic therapy, and most importantly collaboration with those who provide neurostimulation therapy or provides it themself. That is difficult to find outside of those specialists who provide neurostimulation. I found that these specialists understand and respond appropriately to brain injury anger and moral anger, thus validating me. Appropriate response lifts you up, gives hope, and makes you better without draining you.
There is no more excuse for specialists to treat brain injury anger as an anger management issue. Time to heal the injury that causes it, and time for researchers to get beyond prefrontal-cortex-limbic simplistic understanding.
Response to Others’ Anger
A second hidden anger issue is response to others’ anger.
A neurotypical person would at least step back from in-your-face, sudden, top-volume yelling. After my brain injury, I don’t. Although I startle when a squirrel bounces by, I don’t even flinch when a stranger yells in my face. My brain blanks. My body freezes. In response, people either leave or begin to speak to me slowly and carefully like I’m extremely stupid. But none have analyzed why this happens or treated the involved damaged areas so that I can be safe.
In Arizona, a man shot a number of people, killing six, wounding fourteen, including Congresswoman Gabrielle Giffords. The killer’s skewed way of perceiving the world had urged him on. His colleagues and friends identified him as “obviously disturbed,” possibly due to brain damage from alcohol poisoning that had apparently interfered with the man’s ability to perceive. We had dead people and intensive use of police and healthcare resources because it had not been treated.
Not everyone who is mentally ill or has brain injury has damaged perception. But if the ability to perceive oneself is diminished, then understanding other people’s body language, verbal communication, and written language may become difficult. For example, when someone obeys police slowly or stares blankly, it’s clear the ability to understand may still be there but in slow-mo. We must give them patience. It’s the human thing to do.
People who know little about brain injury mistake the fatigue, initiation deficit, lack of motivation, cognitive deficits, anger and irritability, and/or lack of affect as behavioural or psychiatric and ascribe personality defects instead of understanding brain injury is neurophysiological damage. What they’re seeing and hearing is how an injured brain works — or rather not works. Distorting this to personality defects, or as mental illness as defined by the DSM-V, results in the injured person not receiving support, being given medical treatment that worsens or masks, and having to fight for the treatment they need. In that case, privacy laws protect them.
Perception includes perceiving one’s own body. You may lie down straight but feel crooked. One side may dominate your perception, yet it feels normal. How do you correct?
As my perceptual abilities improved, each month I’d look back and go, where was my head last month? But in that month, I’d think, OK, I’m healed now. Then the next month realize nope.
Still, I often had no problems assessing situations for what they were, and that would be confirmed by the professionals.
Malfunctioning perception may make people believe that you don’t understand your brain injury anger and that you’re wrong anger management doesn’t work. So it’s important to understand that we don’t know as much as we think we do about perception — that one may misperceive and perceive correctly at the same time and we don’t understand how that can be — and that we with brain injury understand our anger better than those in the traditional medical model of brain injury care. Again, I found those specialists who provide neurostimulation treatment understood the paradox of damaged perception while retaining good perception. And it helped that they understood brain injury anger and didn’t let its unexpected and powerful appearance influence their perception of me.
†See extensive Wikipedia article on Phineas Gage