Disinhibition

Disinhibition, also referred to as behavioral disinhibition, is medically recognized as an orientation towards immediate gratification, leading to impulsive behaviour driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration for future consequences. It is one of five pathological personality trait domains in certain psychiatric disorders. In psychology, it is defined as a lack of restraint manifested in disregard of social conventions, impulsivity, and poor risk assessment. Hypersexuality, hyperphagia, substance abuse, money mismanagement, frequent faux pas, and aggressive outbursts are indicative of disinhibited instinctual drives.

Certain psychoactive substances that have effects on the limbic system of the brain may induce disinhibition.

Clinical concept
Disinhibition in psychology is defined as a lack of inhibitory control manifested in several ways, affecting motor, instinctual, emotional, cognitive, and perceptual aspects with signs and symptoms, such as impulsivity, disregard for others and social norms, aggressive outbursts, misconduct, and oppositional behaviors, disinhibited instinctual drives including risk-taking behaviors and hypersexuality.

Brain injury
Disinhibition is a common symptom following brain injury, or lesions, particularly to the frontal lobe and primarily to the orbitofrontal cortex. The neuropsychiatric sequelae following brain injuries could include diffuse cognitive impairment, with more prominent deficits in the rate of information processing, attention, memory, cognitive flexibility, and problem-solving. Prominent impulsivity, affective instability, and disinhibition are seen frequently, secondary to injury to frontal, temporal, and limbic areas. In association with the typical cognitive deficits, these sequelae characterize the frequently noted "personality changes" in TBI (Traumatic Brain Injury) patients.

Disinhibition syndromes, in brain injuries and insults including brain tumors, strokes and epilepsy range from mildly inappropriate social behavior, and lack of control over one's behavior to the full-blown mania, depending on the lesions to specific brain regions. The previous several studies in brain traumas and insults have demonstrated significant associations between disinhibition syndromes and dysfunction of orbitofrontal and basotemporal cortices, affecting visuospatial functions, somatosensation, spatial memory, motoric, instinctive, affective, and intellectual behaviors.

Psychiatric disorder
Disinhibition syndromes have also been reported with mania-like manifestations in old age with lesions to the orbitofrontal and basotemporal cortex involving limbic and frontal connections (orbitofrontal circuit), especially in the right hemisphere. Behavioural disinhibition as a result of damage to frontal lobe could be seen as a result of consumption of alcohol and central nervous system depressants drugs, e.g., benzodiazepines that disinhibit the frontal cortex from self-regulation and control. It has also been argued that ADHD, the hyperactive/impulsive subtype has a general behavioral disinhibition beyond impulsivity and many morbidities or complications of ADHD, e.g., conduct disorder, anti-social personality disorder, substance abuse, and risk-taking behaviors are all consequences of untreated behavioral disinhibition.

Substance-induced disinhibition
Certain psychoactive substances that have effects on the limbic system of the brain may induce disinhibition. It is commonly induced by GABAergic depressants such as alcohol, and benzodiazepines.

Treatment approaches
Positive Behaviour Support (PBS) is a treatment approach that looks at the best way to work with each individual with disabilities. In this treatment, a behavioural therapist conducts a functional analysis of behaviour which helps to determine ways to improve the quality of life for the person, rather than trying only to lessen problematic behaviour. Furthermore, PBS relies on the belief in humans' ability to change, and it is most commonly applied to resolving problems in educational settings.

A quick guide for staff to remind about key elements of treatment for a person with disabilities is below. There are two main objectives: reacting situationally when the behavior occurs, and then acting proactively to prevent the behaviour from occurring.

Reactive
Reactive strategies include:
 * Redirection: This strategy can be employed by distracting the person by offering another activity, or changing the topic of conversation. In addition, offer the person a choice of 2 or 3 things, but no more than 3, because this can be overwhelming. In offering a choice, make sure to pause to allow the person time to process the information and give a response.
 * Talking to the person and finding out what the problem is.
 * Working out what the person's behaviour is trying to communicate.
 * Employing crisis management tactic.

Proactive
Proactive strategies to prevent problems can include:
 * Changing the environment: This can include increasing opportunities for access to a variety of activities, balancing cognitively and physically demanding activities with periods of rest, providing a predictable environment in order to reduce the level of cognitive demands on the person, trying to provide consistent routines (be mindful of events that may not occur, try not to make promises that cannot be kept, if unable to go out at a particular time then say so), checking for safety in the home environment (e.g., changing/moving furniture).
 * Teaching a skill: This can include general skills development of useful communication strategies, coping skills (e.g. teach the person what to do when feeling angry, anxious).
 * Individual behaviour support plans: These involve reinforcing specific desirable behavior and ignoring the specific undesirable behavior (unless it is dangerous, the priority is to keep both people safe through a crisis plan which might involve removing sharp objects or weapons, escaping to a safe place, giving the person time to calm down), avoiding things you know upsets the person, strategies to increase engagement in activities.

Broadly speaking, when the behavior occurs, assertively in a nonjudgmental, clear, unambiguous way provide feedback that the behavior is inappropriate, and say what you prefer instead. For example, "Jane, you're standing too close when you are speaking to me, I feel uncomfortable, please take a step back", or "I don't like it when you say I look hot in front of your wife, I feel uncomfortable, I am your Attendant Carer/Support Worker, I am here to help you with your shopping". Also in non-verbal communication, communication can appear in other forms, one could say "I don't like it when you dart your eyes at me in that way". Then re-direct to the next activity. Also, try to ignore any subsequent behavior. Then generally, as almost all behavior is communication, understand what the behavior is trying to communicate and look at ways to have the need met in more appropriate ways.