Perseveration Vs. Defiance

The brain controls every aspect of human skills and behavior. When the front portion of the brain (the frontal lobe) is injured, a brain injury survivor may develop a symptom called perseveration. Perseveration is when a person will persist in repetitive statements or actions seemingly involuntarily. The best way to understand perseveration is to think of the survivor’s brain as if it is stuck in a loop, like a broken record. For example, a survivor with perseveration may click his or her pen over and over to the point that it aggravates all others nearby. He or she may repeatedly wash his or her hands for ten minutes despite the fact those hands were clearly sufficiently cleaned after the first wash. Occasionally, perseverative behavior can present a safety risk. For instance, a survivor with perseveration may have difficulty stopping at a crucial moment when walking and walk right into a busy street.

Perseveration can cause a significant amount of confusion and distress for family and friends of survivors. They may watch the survivor engage in perseverative behavior and attempt to help by telling the survivor to cease the behavior in question. However, as perseveration is a symptom of the brain injury, stopping any such behavior is unfortunately never quite that easy. Even if the survivor says “Ok, I will stop” and makes a conscious decision to do so, this does not mean that he or she is going to be able to put a stop to the problematic behavior. Sometimes this inability to stop is mistaken for defiance. A family member may believe that the brain injury survivor is deliberately refusing to stop rather than understanding this expression of the symptom as a function of the injury. When this same issue comes up again in the future the family member may become even more infuriated, believing that the survivor is now making a habit of defying the family member’s requests. This frustration may even escalate into a confrontation between the family member and the survivor. Perseveration may also be mistaken for a lack of concern on the survivor’s part regarding his or her own safety or as a dismissal of the feelings of others as unimportant. One example involves a survivor repeatedly tapping his or her foot on another person’s chair. A family member may request that the survivor stop tapping in such a way. After the survivor fails to follow this request due to the effects of perseveration, the family member may come to believe that the survivor simply does not care about the feelings of the other parties involved. Lastly, the brain injury itself can even prevent individuals with perseveration from being fully aware of an offending behavior. Often in these situations the brain will send the message, “It is ok, this is normal” instead of recognizing the behavior in question as problematic.

Here are a few tips for working with a survivor coping with perseveration:

1. Patience, Patience, Patience: Remember that it is extremely difficult for this person to control his or her actions due to the effects of the injury. Perseveration is a function of the brain injury in the same way that the survivor may now face difficulty with walking or speech. Family and friends need to be patient with perseverative behaviors just like they are patient with newly impaired physical function.
2. Develop a Signal: For some survivors with perseveration, developing a signal (for instance, a key word or hand movement) for those around them to use as a cue to alert the survivor when perseverative behavior is occurring can be an effective strategy for combating that behavior.
3. Change of Task: For many brain injury survivors with perseveration, the only way to break out of a perseverative loop is to engage in a new and entirely distinct activity. For instance, a survivor may continue to move his or her arm up and down until tasked with a completely separate enterprise such as collecting pieces of paper.
4. Mutually Exclusive Direction: Another way of stopping perseverative behavior is to have the brain injury survivor complete a task that is mutually exclusive to the undesired action . For instance, if the survivor is walking in a perseverative manner, the family member may ask the survivor to hold on to a corner of the wall. Since a person cannot hold onto the wall and walk at the same time, holding on to the wall may help stop the survivor from the unwanted walking.

Learn about brain injury treatment services at the Transitional Learning Center: tlcrehab.org

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