Anger - Fact Sheet

Anger is a common emotional response following a traumatic or acquired brain injury and can be directly related to impairments caused by the injury.

A traumatic or acquired brain injury can result in damage to areas of the brain involved in control and regulation of emotions. Areas of the brain involved in emotional control include the frontal lobe and limbic system [1]. Other effects of a brain injury can contribute to anger and reduce the ability to cope in situations that trigger anger. These effects may include irritability, agitation, lowered tolerance and impulsivity.

A display of anger may have particular characteristics in an individual with a brain injury. For example there can be an ‘on-off’ quality to the anger. The individual may display explosive anger one minute and be calm soon after. Family members and partners may struggle to understand these outbursts. In some cases, a brain injury can impact self-awareness. The person may not acknowledge they have trouble with anger, and may blame others for provoking them. This can also create conflict within a family or relationship. It may take carefully phrased feedback and plenty of time for the person to gradually realise that anger management is an issue.

The major step is to re-learn anger management skills. Coping strategies for managing anger are a skill learnt over many years and following a brain injury may need to be relearned. A good place to start is identifying a pattern in how the outbursts of anger are related to specific frustrations. People can become angry for a number of reasons. A person may feel that their safety/security/comfort is being threatened, that their needs are not being met, it may be a reaction to the frustrations of no longer being able to do things the way they did pre-injury or they feel they are being treated unfairly [2]. Such triggers may originate from the environment, other individuals or internal thoughts. An angry attack, whether it verbal or physical, is often a way of controlling or stopping the source of the person’s anger. Identifying the cause/s of anger can be challenging, however once understood it can be invaluable to assisting with anger management.

Common Causes of Anger

It is important to consider all possible influences relating to:

• The environment e.g. too much stimulation, lack of structure, change of routine.
• The person’s physical state e.g. pain, tiredness, fatigue.
• The person’s mental state, e.g. existing frustration, confusion/disorientation.
• How well the person is treated by those around them.

Recommended Strategies for Coping with Anger – for a person with ABI

These steps can be used by an individual with a brain injury to self-manage their anger. Depending on an individual’s level of self-awareness, learning ability and cognitive skill, assistance from family members or a carer may be required to help the individual with steps to manage anger.

Recognising the benefits

It is useful to identify reasons why it is important to manage anger appropriately. This means identifying what benefits can be expected in everyday life from improving anger management. Reasons include, having better relationships with others, and participating in more social activities.

Recognise the early signs of rising anger (increase self-awareness)

It is important to become aware of personal thoughts, behaviors and physical states associated with anger, such as increased heart-rate, sweating, muscles tightness or raised voice. These early signs may be described as the body’s preparation for attack (verbal, physical) [2]. Awareness of early signals is important to prevent further escalation of anger and to put in place anger management strategies.

Awareness of situations that trigger anger

It is important to become aware of situations, which are associated with angry responses. Such situations may include long lines/queues, crowded malls or rooms, small spaces and certain music or colours. Awareness of these situations may mean avoiding them completely, or preparing before entering such situations.

Coping strategies

As a person becomes more aware of situations associated with anger they can keep a record of events, triggers and associated levels of anger. This can assist with finding coping strategies. Each individual is unique and will have their own triggers and find different strategies useful.

A technique described by the Brain Injury Association of Washington is the “Back off, Calm down and try again technique” [3] This involves a person leaving the situation when early warning signs of anger appear and then moving to a safe place. When an individual is in the safe place the person works on calming down, by listening to soft music or just having some quiet time. When calm, the individual may review the situation and prepare for return. Upon return, the person may need to talk through the issue with someone, explain to anyone why they needed to back off and then resume the same or other activities. Anger cue cards may be useful for some individuals. Family or carers can use cue cards to remind the individual of their warning signs, such as a ‘Loud Voice.’

A similar technique for reducing anger levels is the Stop – Think technique. When you feel anger rising, Stop! and think before reacting to the situation, this may require someone to assist you with creating a cue to signal when you are becoming frustrated. Consider the options for how to respone to your frustration; do you need to walk away, find a better way to communicate or take some time out.

Extra Tips

Recommended Strategies for Coping with Anger – for family and carers

It is important family and carers do not take anger personally and recognise the individual has an impaired ability to control anger due to the effects of brain injury. Below are some tips for coping with anger.

Validation and understanding

Try and understand why the individual is angry, listen to them and validate/acknowledge their feelings and try and find a way to assist the person with finding a solution to the problem- look at what can be done to change the situation.

Maintain structure

Changes in structure or surprises in routine may produce agitation and lowered frustration. Make sure the individual is clear on what is happening and why in all situations, so there can be no misunderstandings.

Recognise the early signs

It may be important for family and carers to help the individual recognise early behavioral signs of anger, such as a raised voice, movement toward the object of the person’s anger, throwing things, making fists. This can be done by calmly communicating to the individual that they are raising their voice or getting too close to you. Again cue cards may be used to help the person realise they are becoming angry and need to calm down. It is very important to avoid the level of anger associated with crisis point, early intervention and diversion is important. Once an individual is at the extreme level of anger it is very difficult for family or carers to use any strategies that may reduce anger.

If anger has escalated and it is safe to do so, it may be important to remove yourself from the person and tell them what you are doing and why “You are getting upset, we are going to leave you for a few minutes so you can calm down” and that you will return when he/she has their anger under control [3]. If the person is being verbally abusive ignore the behaviour by reducing eye contact and verbal interaction.

Distraction

When someone is getting angry, distraction can be useful. This may involve changing the discussion topic, activity or setting. Once the individual has been distracted maybe change the activity to an activity that is generally calming and enjoyable for the individual.

Safety