Implications For Rehabilitation From Brain Injury

Life is often unfair, or so it seems. Not surprisingly, people frequently become angry when confronted with life's inevitable misfortunes, including injury due to accident or disease. For example, a brain-injured patient suffering paralysis or aphasia following a stroke may, like any other patient, experience anger at the seeming unfairness of events. When the anger is misdirected at health care providers, not to mention friends and family, treatment may be disrupted and recovery prolonged. Nevertheless, the anger is understandable, even if unjustified, as the patient comes to terms with a painful event that makes little rational sense.

Such "normal" if misdirected anger must be distinguished from that which results more or less directly from injury to parts of the brain related to aggression. For instance, an injury that results in stimulation of the amygdala may induce an aggressive response that is interpreted post hoc by the patient as anger. As humans, we like to think that our actions are meaningful. When, for extraneous reasons (such as brain injury), we respond in ways that make no sense, we nevertheless impose meaning on the response. Interpreting a brain injury-induced aggressive response as anger is one such meaning-making device. (Recall the earlier discussion of the generic and specific senses of anger. As noted, anger is often used generically to refer to almost any aggressive response.)

One distinguishing feature between normal (albeit misguided) anger following injury and brain injury-induced anger/aggression is that the former is typically manifested soon after the injury's occurrence, and it abates as the patient adjusts to life following the injury. However, differential diagnosis is difficult. Once an aggressive response is interpreted as anger, it is in a sense "normalized"; that is, it is made to conform to the beliefs and rules that help guide normal anger. The underlying condition that produced the aggression may thus be masked.

In short, the assessment and management of anger and aggression in neurological rehabilitation requires careful exploration of the patient's entire repertoire of behavior and the instigating factors. It is easy to be misled by focusing uncritically on a patient's claim that he or she was simply acting out of anger.

The most efficacious treatment of anger and aggression following brain injury requires an individualized rehabilitation program that incorporates an array of neurological, behavioral, and social therapies. In the same way that anger cannot be localized to any specific neural structure, the most effective anger management program will not rely exclusively on any one form of treatment.

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Suggested Reading

Averill, J. R. (1982). Anger and Aggression: An Essay on Emotion.

Springer-Verlag, New York. Berkowitz, L. (1993). Aggression: Its Cause, Consequences, and

Control. McGraw-Hill, New York. Davidson, R. J., Putnam, K. M., and Larson, C. L. (2000). Dysfunction in the neural circuitry of emotion regulation: A possible prelude to violence. Science 289, 591-594. Delgado, J. M. R., and Mir, D. (1969). Fragmental organization of emotional behavior in the monkey brain. Ann. N.Y. Acad. Sci. 159, 731-751.

Panksepp, J. (1998). Affective Neuroscience: The Foundations of

Human and Animal Emotions. Oxford Univ. Press, New York. Patrick, P.D., and Hebda, D. W. (1994). Management of aggression. In Neuropsychological Rehabilitation: Fundamentals, Innovations, and Directions (J. Leon-Carrion, Ed.), pp. 431-451. GR/ St. Lucie Press, Delray Beach, FL. Wheeler, M. A., Stuss, D. T., and Tulving, E. (1997). Toward a theory of episodic memory: The frontal lobes and autonoetic consciousness. Psychol. Bull. 121, 331-354.

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