Cognitive Changes after Encephalitis
Recovery and Rehabilitation
This page has been taken from Encephalitis – a guide, which was compiled by Elaine Dowell and Ava Easton with advice and assistance from the Society’s Professional Advisory Panel and members of the Encephalitis Society.
Cognition is the conscious process of the mind by which we are aware of thought and perception, including all aspects of perceiving, thinking and remembering. In general, cognition is knowledge – the way we learn, perceive and process the world around us.
When thinking of cognitive problems it is useful to remember that no human skills operate in isolation. We depend on a combination of several skills to carry out individual tasks. For example, if we want to remember what someone is saying to us we firstly have to attend to what they are saying (concentration), understand what they are saying (language / information processing) and keep up with the flow of conversation (speed of thought). Responding to what has been said requires even more skills.
Similarly, a loss of one skill can affect another skill. For example, a memory problem can actually be the result of an attention problem. For this reason, it is important for the person affected by encephalitis to have a neuropsychological assessment, which will more precisely identify the areas of difficulty.
Lack of Insight
Individuals affected by encephalitis may have great difficulty seeing and accepting changes in their thinking and behavior. The person may deny the effects of the injury and have unreasonable expectations about what they are able to do. They may be unaware of the effect their words have on others so do not see the need to amend their behavior. Lack of insight is sometimes called “denial”, and people who are confronted by their deficits may become anxious, depressed or angry. Making the person aware of what they can and cannot do may result in a lack of self esteem and confidence.
Problems with memory can take many forms. Memories that existed before the illness may be disrupted. This disruption may be more severe for memories formed nearer the time of the illness. This applies to most kinds of memories, e.g. faces, events, meanings of less common words. Skills such as typing, swimming, riding a bicycle are not usually affected unless there is an associated muscular weakness.
The ability to form new memories may be affected, with the person forgetting new information such as faces and names within minutes. Instructions will be forgotten unless continual reminders are used. Remembering to do things and forgetting that things have been done (e.g. putting the kettle on, running a bath) may also occur frequently.
Memory problems are for many individuals post-encephalitis, a major problem. At the moment it is not possible to restore damaged memory systems in the brain. However, there is much that can be done to help individuals to function more effectively on a day to day basis. Strategies such as the use of diaries, calendars and electronic memory aids can make a huge difference. Highly recommended is the book “Coping with Memory Problem” by Linda Clare and Barbara Wilson (copies are available from the Encephalitis Society).
A very common outcome is a tendency to lose concentration or be distracted easily. This difficulty can manifest itself in the inability to focus on a task or idea and ignore or filter out distractions, such as someone walking into a room. The best way to help with such problems is to keep all possible distractions to a minimum. Keep to one task at a time: for example if the person is making a cup of tea, do not try to have a conversation.
Speed of Information Processing
Individuals affected by encephalitis may have difficulty absorbing new information whether it is presented verbally, visually or in written form. A reduction in speed of thought may occur resulting in a slowness to answer questions or to perform tasks. They may have difficulty keeping up in conversation and their capacity to respond quickly in an emergency may also be lost. The best way to help is talk at a slow steady pace and make sure one piece of information has been absorbed before giving the next.
Poor planning and problem solving
Individuals affected by encephalitis may have difficulty solving problems and planning and organizing things they have to do. They may be inflexible in their thinking, becoming fixed on one particular thought and unable to consider alternatives. The best way to help is to make sure complex tasks are broken down into step-by-step sequences.
Perceptual, Visual-spatial and construction skills
Perception involves interpreting information that we receive from our senses. Some people may lose the ability to recognize the taste of food or appreciate the difference between hot and cold. Some people lose the ability to judge distances and may appear clumsy. Some people may have ‘neglect’ for one side of pictures or body: for example they may only shave one side of their face.
Lack of initiative
This may be because some tasks seem so difficult that it seems easier to not attempt them. For some people the ability to plan and set goals may be lost completely, for the short or long term.
Individuals affected by encephalitis may lose the control system that makes them stop and think before jumping in. They may have difficulty judging situations and behave in an unpredictable way. This can lead to a wide range of behavioral issues and problems with relationships, finances and sometimes with society more generally.
Irritability and Anger
Many individuals have a reduced ability to tolerate any kind of pressure or noise. They tend to have a low tolerance for frustration, becoming irritated by trivial things and losing their temper easily. Unpredictable outbursts of uncontrolled rage can be very frightening to others. These outbursts are usually directed at the family only, which can be particularly difficult to take. Many demonstrations of aggressive behavior are because the person affected by encephalitis feels relaxed and safe within the family and so vents their frustrations on their loved ones. The best way to deal with outbursts is to walk away from. Help with managing anger should be sought from a psychologist who understands about brain injury.
Socially inappropriate behavior
Individuals may have difficulty judging how to behave in social situations. They may be over familiar with strangers or they may make inappropriate sexual advances.
This can be incredibly difficult for families or partners to deal with. A lack of awareness and insensitivity can also result in unsatisfactory sexual relationships.
When talking we need to choose which words to use and put them together. We also need to speak these words at the correct volume and speed and with the correct tone and inflections. Communicating with others also requires us take turns in conversations, interpret and respond to social cues, show interest in others, use humor appropriately and shift between topics of conversation. Individuals affected by encephalitis who have word finding difficulties, impaired listening skills and memory problems can become isolated as these difficulties impact on their communication skills. Some people may also have difficulty in understanding multiple meanings in jokes or sarcasm and may have difficulty identifying individual words or breaking down the structure of sentences to extract their meaning. A Speech and Language Therapist may be able to assess and help with these problems.
Individuals affected by encephalitis may sometimes appear self-centered, and lack consideration for the feelings and needs of their family and friends. This lack of warmth and empathy can be very distressing to close family and friends, leading to resentment among family members and friends and social isolation for those affected.
Some individuals lose control of their emotions and tend to overreact. They may cry too much or too often. Others may laugh at inappropriate times or suffer rapid mood changes, crying then laughing a moment later.
Anxiety is common as people affected by encephalitis find tasks that used to be easy, more difficult. This in turn reduces self-esteem and confidence. Individuals can often be frightened of going out alone and experience panic attacks. Some may develop obsessive / compulsive behavior.
Depression is a normal reaction to loss for all of us. The person affected by encephalitis may feel that they have “lost” the person they were and that life will not be as it was. A distinction needs to made between “normal” sadness and grief and an inability to express feelings at all. Professional help or counseling may be needed.
Post –traumatic stress
It would not be unusual for a person who has undergone such an ordeal to be left with anxieties and stress. Sometimes people describe experiencing flashbacks, panic attacks, feelings of paranoia and ongoing ‘night terrors’ or nightmares. You should seek a referral to a neuropsychiatrist via your GP to help you understand, address and where necessary treat these problems if they outlast the acute stage of encephalitis.