Knee-jerk Reactions and Why They Happen
One of the most surprising and sometimes exasperating responses of the individual with dementia (IWD) occur entirely from what has been called the emotional brain. The unbuffered and often unexpected responses, physical strikes, and unfiltered language come straight from the emotion centers of the brain. They are not interpreted by the cognitive curbing typically used to determine social correctness. A cognitively intact brain may weigh consequences before an action is initiated or comment is made. One with dementia may not have the ability to do this.
The emotional brain does not think, monitor, censor, or interpret cues from the environment. It simply responds to sensory input. Daniel Goleman in the ground-breaking book Emotional Intelligence, discusses the origin and development of different parts of the brain and explains that emotion centers developed prior to cognitive ones (Goleman, 1995). Emotions are fed by our body’s senses and are ‘subconscious reactions to physical experience’ (Alkon, 2018). The brain picks up these bodily changes of others (facial expressions, body posture, gestures, etc.) and sends this information directly to the brain. In much the same way, it then incorporates our own personal sensory changes and messages. We might not be consciously aware of these changes or the incoming sensory messages themselves. Feelings happen later and make sense out of the emotions through our memory, beliefs, and associations.
The most primitive area of the brain is the brain stem. Located at the top of the spine, it regulates our automatic bodily functions like breathing, heartbeat, organ metabolism, and stereotyped movements and reactions. With this part of the brain, there is no thinking or learning. It does its job automatically. The next section of the brain to form (and this has been observed in neonatal development) is the area of the brain called the emotion center. This area of the brain holds the emotional information gathered from our senses. The sense of smell, based in the olfactory lobe, was the first to evolve in this area of cells that encircled the brainstem. Again, according to Goleman (1995), every living thing has a distinctive scent or pheromone. The interpretation of this scent allows the object to be recognized as feast or foe, edible or sexually available. The next layer of cells in this area sends reflexive messages to the rest of the body as to what response is warranted: eat, bite, avoid, chase, etc. Proper emotions were only added to the brain with the development of the limbic system, which enabled us to have more varied responses (avoid that tree with the bees- got stung last time) and comparisons (some smells are better than others). In this way, emotions came to have the purpose of starting or stopping something (Chin and Howatt, 2018). These emotion centers have immense power to influence the functioning of the rest of the brain—including its centers for thought (Goleman, 1995). So, what implications does this have in dementia?
In dementia, these emotion centers can hijack responses before they can be interpreted by the thinking areas of the brain. The response generated from sensory input isn’t buffered by the prefrontal cortex. This means the thinking part of the brain is unable to weigh reactions before they occur, and the reaction to the information may be made very quickly. In the unaffected brain, the prefrontal cortex, most likely the left prefrontal lobe, regulates the unpleasant emotions of fear and aggression that are located in the right prefrontal lobe. This regulating left prefrontal lobe can put a stop to reactions of biting, kicking, punching, etc. until a cognitive interpretation or association can be made. We see this in stroke patients where damage to the left prefrontal lobe results in “catastrophic worries and fears”: damage to the right prefrontal lobe can result in more affection, cheerfulness, and a more even disposition (Goleman, 1995). We also see it in lobotomy patients when the links between the prefrontal lobes and the rest of the brain are cut. In this case, emotional responses do not occur.
Emotion lasts longer than cognition. An example of this would be the euphemism of getting up on the wrong side of the bed in the morning. If the day begins on a sour note, the rest of the day may be tainted by that lingering mood. Another example is the impermanence of an idea prior to its implementation – I knew I went into this room to get something but cannot recall what that something was when I got there. Therefore, it is especially important to remember the IWD does not function with an expansive repertoire for interpreting sensory data. They may not have the cognitive ability to reason away or regulate an emotional reaction. If we raise our voice or startle them, their response –withdrawal, fear, anxiety, whatever – can last long after the memory of the event. They might not remember that it was the morning caregiver or a warning not to do something unsafe that was in their best interests. The emotion stays. If we start an interaction that agitates the individual, they may continue to stay agitated for some time. To avoid surprise and engage without upset, move slowly, approach from the front, respect personal space, use a calming tone of voice, and wait for a response.
Likewise, we need to validate emotions. In The Gang Intervention Handbook, (Goldstein and Huff, 1993), social skills are taught in a step-by-step manner to students in need of interpersonal skills training. The first step to the skill of Understanding the Feelings of Others is to be observant of the other person. This observation includes tone of voice, posture, facial expression, etc. The second step is to listen to what the other person is saying. In dementia, the words might appear at the surface to be unclear, jumbled or disconnected, but the content may still be understood. Theodore Reik spoke about ‘listening with the third ear’. We need to be in tune with our own intuition about what is being said and examine the context in which that message is conveyed (Reik, 1948). After listening—and only after listening – comes Step 3: Figure out what the person might be feeling. This is where all the above information is proposed into our hypothesis. We determine the person might be sad, anxious, angry, etc. Step 4 is to think about ways to show you understand what he/she is feeling. Here we add a repertoire of responses to OUR interpretation of what the individual is feeling. Responses might include telling him/her you understand, a light reassuring touch, leaving them alone, or, hopefully, trying to meet the expressed need or concern. Step 5 is to decide on the best way [to respond] and do it. If we follow these steps to decipher the seemingly impulsive behavior of the IWD, we can usually discover what message is being conveyed. At the bottom of this skill, the authors’ comments include: “This skill is closely related to empathy…” Need I say more?
Just as emotional responses are fundamental to cognition, social experience is critical for maintaining brain health and connection with others. The social network provides stimulation to both the emotional and intellectual areas of the brain and may somehow decrease the effects of cognitive impairment. These emotional connections to others give meaning to life—and a sense of purpose to those with dementia as well as those without.
Sources:
Alkon A. Hijacked no more: How to tell your feelings to beat it so you can stop drowning in the quicksand of you. Psychology Today, 2018: 2:60-67.
Chin E, Howatt B. The science of anger. Good Housekeeping, 2018;3:47-52.
Goldstein A, Huff CR. (1993). The Gang Intervention Handbook. Champaign, IL: Research Press.
Goleman D. (1995) Emotional Intelligence. New York, NY: Bantam Books.