Emotional Lability Following Brain Injury

Saying a very big thank you to Headway for inviting me to give this talk today.

As Tamza said, my name is Warren Dunga. I’m a clinical neuropsychologist and I particularly work in neurorehabilitation, and I’m also a director on the Clinical Psychology Doctoral Programme at the University of Southampton.

Even more importantly for today, though, I am also on the Board of Trustees for Headway Portsmouth and South East Hampshire. So I’ve seen first-hand the amazing work this charity does to support people whose lives have been affected by brain injury. It is a true pleasure to be delivering this talk today.

We’re going to have 30 minutes for this talk, and it’s going to be a brief overview of what can be quite a complicated topic that, in my experience, is often quite misunderstood.

My aim for this session is that, by the end of this talk, you’ll have a better understanding of what we mean by emotional lability following brain injury, and I’d like you to have some ideas of what you can do to help.

My hope is that it’s going to be helpful for those of you who have personally been impacted by brain injury, as well as for any professionals who are attending today who’d like to know a little bit more about this topic. I hope I’ve pitched it at the right level, but please do ask questions and we can address anything at the end.

My approach to this talk has been particularly informed by my experiences as a clinician working with real people who’ve experienced emotional lability, but I’ve also referenced various research throughout as well.

To set the scene, emotional changes following a brain injury have been recognised for a very long time, and even Charles Darwin himself commented on this in his book The Expression of the Emotions in Man and Animals.

But what is it?

Firstly, emotional lability has many different names, which can make it very confusing when we’re reading about this in books or papers or leaflets. We’re going to simply refer to it as emotional lability today.

Emotional lability is characterised by these kind of uncontrollable episodes of crying, laughing, or both. These are usually very short-lived. These are very short, sudden reactions that you will see.

So you might have someone who is seeming absolutely fine one moment and then, almost out of the blue, suddenly becomes quite tearful, and then within a few seconds to minutes it’s gone again. They’re these really short, sudden little expressions of emotion that we might see.

These emotional reactions might come across as quite disproportionate or more intense compared to what you might expect in that situation.

For example, you might react more strongly than you would before to an emotionally triggering event. A client I work with said to me, over one Christmas he was sat at home watching television and the John Lewis advert came on. I always think that’s a bit of a tearjerker anyway. He suddenly was overwhelmed with emotion. He said he got so tearful watching it, and he said it had never happened to him before he had his stroke.

So this was a big, big change to him in how he experienced emotion and how this was shown.

But the emotional reaction could also be completely unrelated to the situation and it might happen for no obvious reason. That can obviously be quite confusing for the person themselves, but also for other people who might not understand what’s going on.

It’s important to recognise that emotional lability can be completely unrelated and independent of mood. So you may not feel sad or depressed even though you might be showing some tearfulness. I’m going to come back to that point in just a moment.

It’s also important to recognise that emotional lability represents a change in how you normally experience emotions since your brain injury. This is likely to be more obvious for the person themselves or their loved ones, who know them really, really well.

Although some people say that this can also present as irritability or frustration, I’m going to mostly focus on tearfulness and, to a lesser extent, laughter for the purposes of this talk.

I also just want to acknowledge that this can occur in a range of other neurological conditions as well. But I’m going to mostly focus on acquired brain injuries like stroke or traumatic brain injury, again for the purpose of this talk.

What does emotional lability look like?

Here I’ve put some quotes that are from different research studies on emotional lability, and also from some of my own clients as well, that give you a little bit of an idea of what it’s like.

For example:

“I get no warning. Just one minute I’m okay, the next minute I burst into tears. It could be a happy thing, it can be a sad thing, or it’s just for no reason.”

Or:

“I find it very difficult at times to control it. It’s terrible. What gets you is you can’t control it.”

And then someone else said:

“You just have tears for a minute or so and then it stops. It’s these short bursts.”

So already this gives us an idea of something that comes on without necessarily any warning. It might come in response to a range of different triggers, and also it’s very short-lived. It comes, it goes, which understandably can be quite confusing.

It’s quite a common problem after brain injury. If we look at people who’ve had a stroke, within that first six months of their recovery about one in five people will experience emotional lability. After those six months it becomes a little less common, so you’re seeing about one in eight people there.

Generally, it’s found that crying is a lot more common than laughter, so we’re much more likely to see that. But again, many people might experience both.

If we think about traumatic brain injury, about one in ten people experience emotional lability within that first year of their recovery.

But with certain types of brain injury it can be even more common. We’ve got something called limbic encephalitis. Encephalitis is inflammation of the brain, and actually for this particular type it’s about one in two people, so that’s 50%. Really common.

When you consider all of this in the context of around 335,000 people being admitted to hospital every year with an acquired brain injury, we suddenly start realising that emotional lability likely affects a lot of different people.

Actually, in my experience, when I used to work on a stroke ward, I felt it was more common than the research suggests. In my experience it was about one in three people. I think it was really common in those early days of recovery.

Emotional lability and depression

As I said, it can be a bit confusing. Emotional lability can frequently be confused with depression.

Depression is more of a prolonged emotional state that’s associated with feeling sad, worried or struggling with motivation. You might have feelings of hopelessness and have a negative view of yourself, others and the world.

In contrast, emotional lability is this relatively short expression of emotion that’s usually completely independent of mood or how that person is actually feeling.

When I’m working with someone who becomes quite easily tearful, I will directly ask them and check in if they’re actually feeling sad or if they’re showing any signs of depression.

An analogy that’s quite useful, that’s been used for this before, is suggesting that emotional lability is a bit like the weather: short and changeable, particularly in the UK. Whereas depression can be likened more to climate. It’s more like a long-term pattern of weather that might stick around for longer.

Someone might still present with both emotional lability and depression, but it’s important to remember they can occur completely separately.

It’s therefore really important for clinicians to properly assess for this, and I’m going to come back to that point towards the end of the talk.

Why does emotional lability happen?

It’s not fully understood why this happens after a brain injury, but there are a few theories. One of these involves a circuit of different brain structures that are involved in how we express emotions.

Now, don’t get worried about that very complicated term that I’ve put there! I’m going to give an oversimplified explanation of what this means.

Essentially, within the brain there’s like a gateway that stops inappropriate emotions from being expressed.

So when an emotion is about to be expressed, it’s waiting at the gate. Your brain checks with other parts of your brain and goes, “Is this the right emotion to show in this situation?”

Those brain regions will check what’s going on and they might go, “Yes, it is,” so the emotion is expressed. Or, “No, it’s not,” so the gate remains closed and the emotion is not shown.

But what happens after a brain injury is that gateway is not working as well, or it’s left open. So emotions are much more easily expressed, and they might be expressed at times when it’s less appropriate.

Also, because this is a circuit in the brain, it involves many different parts of the brain. What can happen is you might get a kink in the circuit anywhere along that circuit.

This is why it could be so common, because actually you could have lots of different types of brain injury, or strokes in different areas of the brain, and you still can experience emotional lability.

Triggers

There are many different things that can trigger emotional lability. When I use the word “trigger”, what I mean is something that causes it to start.

You’ll notice from my list here that it’s not always a sad emotion that might trigger emotional lability.

In fact, in my experience, the most common trigger that I have seen is acts of kindness or expressing gratitude for someone who’s been really kind.

I used to see it all the time on the ward, where someone would be telling me about these wonderful nurses and wonderful staff. They’ve been so helpful, and whilst they’re talking to me about that, suddenly the tearfulness comes on.

So it could be anything with a bit of an emotional charge, whatever that emotion might be, that can suddenly bring on emotional lability.

Of course, that could also be things that are sad or emotional. So we’re watching something sad or a touching news story on television. But again, that reaction is much stronger than it was before, and it’s a big change for that person.

There’s also something a bit odd about bringing attention to emotional lability that inadvertently can make it worse.

If someone I’m working with is getting tearful, if I point it out and just go, “Oh, I’m just noticing when we’re talking that you might get a bit tearful at times,” suddenly the tearfulness comes on even stronger.

If you consider how someone might typically respond to seeing someone cry, we try and console them. We might put a hand on their shoulder. We might go, “Are you okay? It’s all right. No worries.”

But then that little act of kindness inadvertently fans the flames, and before we know it the tearfulness is even worse.

Similarly, if someone starts laughing, if that’s the emotional lability they experience, we might start laughing with them, which then leads to them laughing more. So again, we fall into a little bit of a trap here where we’re suddenly making emotional lability a bit worse.

I’ll also just add that I haven’t got fatigue on my list there. I don’t think fatigue necessarily is a direct trigger for emotional lability, but it can certainly make people more vulnerable to it, from my experience.

So we might see people become more easily tearful at the end of the day when they’re quite tired.

The impact of emotional lability

If we consider the impact of emotional lability, once the trigger has happened and the emotional lability has shown itself, first of all the good news is there’s typically no direct harm from experiencing this.

As we said, for many people this might resolve after the first three to six months of recovery.

However, there may be indirect or unintended consequences.

Because of showing that sort of sudden tearfulness, people might start feeling quite embarrassed. They might worry about showing that tearfulness or crying in front of other people, and this might be really distressing for some people.

This can be so significant that the knock-on effect is that people might start avoiding things because of it.

They’re so worried or embarrassed about showing this emotion out of control that they avoid people or having visitors. They might even avoid rehabilitation: “I don’t want to go. I don’t want the therapist to see me all emotional.”

They might even stop leaving the home.

Because of that withdrawal, because of that avoidance, what we can then see is an increased risk of depression, anxiety and other mental health difficulties. So we can see how these unintended consequences can have some big, big impacts for people.

A really important thing to consider here is people’s appraisal or interpretation of what expressing emotion means to them.

What does showing emotion mean to that person?

This is very individualised and, from my experience, it’s the biggest predictor of whether or not someone becomes distressed from experiencing emotional lability.

For example, I used to work with a lot of people who were ex-Navy, so in the Armed Forces. For them, it was a big, big change to suddenly become very tearful and show that in front of other people. Because of that, they were really worried about what other people would think, whether they thought they weren’t coping very well, and they might start shutting themselves off.

So that interpretation, what does having emotional lability mean for that person, is really important.

As a result, what I think is important to add is that we must consider emotional lability in a social and cultural context.

What does showing emotion mean in this particular social or cultural context?

For example, in the UK we have the “stiff upper lip” or “keep calm and carry on”, or even stereotypes that men shouldn’t cry or show emotion. All of this can add to someone’s experience of feeling embarrassed or worried if this happens to them.

These indirect consequences can happen for uncontrollable laughter as well.

I worked with a gentleman who, after a stroke, would experience these episodes of laughter. Most of the time it was fine, but then suddenly he said to me, “I’ve got to go to a funeral.”

He was really worried: what happens if I suddenly laugh while at the funeral?

In that social context of attending a funeral, suddenly expressing that emotion might seem less appropriate. So he was really worried about this.

Whatever your experience of emotional lability, it can have a big impact on you.

Some of the other impacts that can come from this are misunderstandings from other people. Other people might see you becoming quite tearful and assume that you’re depressed or sad.

It might be really hard to explain to people why you might be suddenly crying or laughing. It might be that you don’t understand it yourself, because perhaps no one has ever explained to you that this is a common symptom of brain injury.

And, as we said before, even just people responding with kindness and compassion might inadvertently re-trigger those emotions and make it worse.

All of this can impact on our self-identity, our sense of who we are.

I’ve got a quote there from someone I worked with who said:

“I wasn’t an emotional person before, but now I feel all over the place.”

This was someone who prided themselves on being a very composed person. “I didn’t show emotion, and now suddenly I feel like I’m an emotional wreck,” they described themselves.

So that might have a big impact on your identity, alongside all of the other changes that we know can sadly come with a brain injury.

If you want to know more about identity, I’d highly recommend Fergus Gracey’s excellent Headway webinar on identity.

What might help?

With all this in mind, what might help?

I’ve put together a list of common strategies that I’m hoping you’ll be able to use, and other professionals can recommend, to try and help.

The first of these is what we’re doing today: education and normalisation.

We want to educate people with a brain injury and their family about emotional lability, emphasising that this is a common symptom of brain injury.

This doesn’t reflect on your character. It doesn’t suggest you’re not coping. This is because of changes in the brain.

The gateway is open, and it just means that you express emotions much more easily than before.

So we can provide that reassurance and that validation. This might be really confusing. This is probably really worrying. But do you know what? It’s a very normal reaction.

The next thing that I think is really helpful is learning your triggers and making a plan.

In that list of triggers I showed before, it’s very individualised what might trigger your emotional lability. So what I think is really helpful is to keep a diary of when it happens.

What were you doing? What were you thinking? Who were you with when it came on?

This can help you to start to recognise your own triggers for emotional lability.

It might be that you could avoid some of those triggers if possible, but I’m going to add “if appropriate”. That’s because we might fall into that pattern of avoidance which might be more harmful.

For some triggers, you might be able to avoid them. But for others, don’t avoid your family, friends or rehab. Those are things you might want to keep going.

Once we know those triggers, we can make a plan. What do we do when this happens? Do we ignore it? Do we change the topic? Do I need a bit of a time out?

Relating to that, my next point is that we then communicate that clearly to the people around us.

We want to help other people understand how you’re feeling, what those triggers are and when emotional lability comes on, so they understand and we don’t have any of those misunderstandings.

So we might say:

“I’m not sad. I just get tearful for no reason since my stroke.”

We then let people know how you want them to respond.

Do you want them to be reassuring, give you a hand on the shoulder, or would you like them to step back and give you a bit of a break? Change the topic? Whatever you might choose.

Distraction is a strategy that many people have found helpful.

That might be just changing the topic of conversation. If talking about family was the trigger, we might switch the conversation topic.

Other people have found that practising little mind games is quite useful for distracting the mind. So counting, or I might say, “Right, name five things in the room that are blue.”

That little bit of mental distraction can sometimes just take the emotional lability away.

You could try doing a different activity, or even just have a bit of a time out. Give yourself a bit of a moment and then return to what you were doing.

There are a few studies that suggest that deep breathing and relaxation could also be quite helpful.

When you notice the trigger has happened and the emotional lability is coming on, you can feel it start. Doing that deep and slow breathing, and it is something you’ve got to practise, can sometimes take the sting out and help that emotion come and go.

Similarly, we might notice that when it comes on our muscles start tensing and we get a lot of tension in our body. There are some lovely strategies around something we call progressive muscle relaxation that can help us let go of that tension in our body, which some people find helpful.

Listening to music can also be a wonderful way to relax if you notice it coming on.

Some people have their favourite songs they listen to when it comes on that they feel also helps distract them, helps take their mind off it, and then they can carry on with what they’re doing.

Also, as we know with brain injury, lots of other symptoms and problems can happen at the same time. Some of these, as I mentioned, like fatigue, can make emotional lability worse.

So practising strategies to manage some of those other symptoms can be really helpful.

With fatigue, we often get stuck in a bit of what we call a boom-and-bust pattern. I power through and then I crash at the end. While I’m in that crash period, I’m probably more likely to experience emotional lability.

Practising things like pacing or planning to manage fatigue, where you do little bits at a time and rest regularly, might help you conserve your energy. You might find that you’re more resilient to emotional lability.

As I mentioned before, because of that pattern of avoidance that people really easily fall into, it’s really helpful to stay focused on the goals and what the bigger picture is for you right now at that stage of your recovery.

Keep those important goals in mind to try and help you stay on track.

Notice that urge to avoid, and then remind yourself of that bigger picture.

So: “I know I’m worried about what other people will think, but my physio sessions are really important, so I’m going to go. I’m going to go and do it.”

Keep that in mind as we’re going along.

There’s another interesting idea. A couple of studies have found this to do with muscle movement.

First of all, notice which muscles are affected by an episode of crying or laughter. It might be that you notice you get quite tense up in your shoulders when it’s coming on, or maybe your face tenses up a certain way.

Then, when you notice an episode is being triggered, you intentionally move those muscles into a different position. Change posture, stretch your mouth out, things like that.

Or, almost like I say, shake it off. I’m going a bit Taylor Swift now, but shake it off!

Sometimes it can help just shift the emotional lability off. So it’s just another little strategy that might work for some people.

There is also medication that might be able to help with emotional lability too.

Now, this is going to sound a bit odd considering what I was saying earlier, but the most common medication that can help with emotional lability happens to be antidepressants.

It’s important to recognise that, in this context, it might not be being used to treat depression, but instead to treat symptoms of emotional lability.

So if you’re a bit confused, if you happen to be on one and you’re not sure quite why, “I’m not depressed”, it might be for the emotional lability. Do check with your medical professional if you’re not quite sure.

The other big thing to keep in mind with all of this is that, if in doubt, you could just wait.

As we said, for many people it resolves in that first three to six months following a brain injury.

So it might simply be that you use some of the other strategies to keep you going in the meantime, and then it might resolve and it might go away.

Acceptance

But what happens if it doesn’t?

Well, this is where I’m going to say that horrible A-word that I know people don’t like: acceptance.

What might be important is that, as part of living with a brain injury, we practise acceptance.

One way is around just allowing the emotional lability to come and go. Letting it out.

There are some suggestions that actually suppressing it might make it worse. If we try and bottle it up and we fight it, it might be less helpful.

Some people have just said, “Letting it out. It comes, it goes, and then I can carry on with what I’m doing.”

Other people have said it’s quite helpful to acknowledge emotional lability with humour. Make a joke out of it.

I’ve got a quote there which says:

“We have a joke about it and then it’s okay. My family are very good, especially my grandchildren. They tend to help by laughing it off and telling me it’s all right.”

Again, I’d add: if appropriate.

It might be, for you and your experience, that emotional lability is still really distressing. Obviously it wouldn’t be appropriate then to make a joke of it.

But if that clicks with your personality, if that’s the kind of person you were, humour might be a good strategy for you.

The final one is a particular therapy we call Acceptance and Commitment Therapy, or ACT for short.

I think this could be quite a useful set of strategies.

This would work around focusing on accepting the symptoms of emotional lability and not letting them interfere with living your life in a valued, meaningful way.

This therapy can help address some of the indirect consequences, like the distress. It does this thing we call “dropping the struggle”.

What that means is that, rather than fighting with emotional lability, trying to suppress it, trying to ignore it or avoid it, we drop the struggle. We let it come, we let it go, and then we get on with the things that are important to us.

Currently there are no known studies that have used ACT for emotional lability, but from my own clinical practice I think it has been really helpful for some people.

Putting together a plan

So I’ve thrown a lot of strategies at all of you now. You’re thinking, “Overwhelmed! So many ideas. What do I do with all of these, Warren?”

I’m glad you asked.

What I like to do with people I work with is put together a helpful summary of their experience of emotional lability.

This is what it looks like.

At the top it says:

“Because of my brain injury, I sometimes find it hard to control my emotions. When this happens, you may see me…”

Then I would add in their experience:

“…suddenly become tearful,”

or:

“…laugh at inappropriate times.”

Then we’ve got:

“My triggers include…”

That’s where we can add in those specific triggers for that person, what you’ve recognised. So talking about family, watching something sad on television, someone showing kindness. You can add them in there.

Then:

“When this happens, I would like you to…”

That’s your chance to communicate to people. How do you want them to respond?

Do you want them to ignore it? Do you want them to change the topic, or something like that?

It’s really helpful to share that with people so they know.

It can look often odd, I think, with me because when I’m in sessions with people and we’ve agreed in advance that I will ignore it if it happens, I probably look like a very uncaring psychologist because people will start crying with me and I act like nothing’s happened!

But I assure you, we have pre-agreed this. It’s part of the plan.

You can decide how you want people to respond and include that on your plan.

The last part is:

“My strategies which help me include…”

That’s where you can add in which specific strategies you’ve found helpful.

Is that distraction? Is that deep breathing? Is that moving around and shaking it off?

All of this will help prevent misunderstandings.

You can share a summary like this with your family, your friends and health professionals. It might also prevent that kind of re-triggering of emotion because people know how to respond to it.

I always say with these plans, make them individualised and adapt them to the person.

For some people, they prefer a visual summary. This is an example of one that I’ve done with someone else before, where we had a little visual summary of emotional lability and then we’ve got the strategies on there for that person.

Think about how we might want to adapt it for that person, just to make it individualised and specific to them.

For clinicians

For the clinicians attending today, the big thing I would emphasise is that it’s really important, if someone is presenting particularly with tearfulness, that you measure both depression and emotional lability to help distinguish between the two.

I’ve listed a few different emotional lability measures there that you might be able to use.

It’s really important to emphasise, though, that a lot of these measures only assess frequency: how often does emotional lability happen?

They don’t tend to ask about the impact, that appraisal or interpretation of what emotional lability means to that person.

One of the things I like to add to my versions is a little one-to-ten scale where I ask someone:

“How much does the crying or laughter bother you?”

Because actually, if it doesn’t bother them very much, it’s a low score, we might not need to do anything about it.

However, if it’s at the higher end and it’s bothering someone a great deal, then I know that’s really important. We need to do something. We need to work on it.

That might just help guide your interventions a bit more.

Future research

Looking ahead at future research, there’s a lot more research that needs to happen.

All the strategies that I’ve outlined today, some of them come from just one individual study that might only be a single person in that study. So it’s a very small evidence base.

There’s very, very little research out there on emotional lability interventions, so we need to do a lot more.

It’s also quite unclear whether, with emotional lability, we should be targeting stopping it altogether or whether it’s more about learning to live with it. There are conflicting findings, so we need to learn a lot more about that.

If you’d like to know more about future research suggestions, I’d recommend that paper by Broomfield, which has got some really helpful suggestions.

Summary

Pulling all of this together, emotional lability is a really common symptom of brain injury, particularly during those really early stages of your recovery.

Although it’s unlikely to cause any direct harm, the indirect consequences can result in avoidance and an increased risk of developing mental health difficulties.

So it’s really important that we educate people about this, normalise their experience of emotional lability, learn your triggers, and then find which specific strategies work best for you so you’ve got that individualised plan.

Acceptance-based approaches, in my experience, I think might be really useful, but we definitely need a lot more research on that topic.

If you’d like to know more, or if you’ve got any concerns about emotional lability, do contact your local Headway.

You can also check out the Headway webpage on emotional effects of brain injury, and Queensland Health has got a very helpful summary of strategies for emotional lability that you can also access online.

But, as always, do speak with your health professionals if you need any advice.

If you’d like to know more about this topic from a research perspective, I highly recommend the work by Niall Broomfield, David Gillespie and Fergus Gracey. They’ve done some wonderful work on this topic, all from the last few years.

It’s a really up-and-coming area, so do check them out if you’d like to know more.

My final point is just to extend the analogy from earlier. I want to emphasise that even if you experience changes in your emotions like the weather, or even if this leads to changes in your mood like the climate:

You are still you after your brain injury. You are the sky.

Thank you very much for your time, and I’m very happy to take any questions.