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next section presents tables outlining causal features for BC, resulting from an audit undertaken of the case work of a member of the NCBT (Makin 2009).
| Table 2.1 The common biopsychosocial causes of shouting | |
| Shouting – one needs to distinguish the various forms of shouting – shrieks, moans, repetitive words or sentences. Also one needs to determine frequency, timings and triggers | |
| BiologicalPain, resulting from joint/dental/problemsDiscomfort due to skin, bowel problems, including constipationFrontal lobe deficits leading to perseverative behavioursResponse to hallucinationsDrug induced restlessnessInfection induced confusionEffects of alcoholHunger/thirstTiredness reducing threshold for irritability | PsychologicalAnxiety/fearAnger and/or frustrationFeels threatenedLonelinessBoredomSelf-stimulate, particularly if deafOver/under stimulated |
| Social and environmentalRequest for toiletRequest for food or drinkRequests are being ignoredCommunication difficultiesRejecting carers’ approachesSignalling dislike of someone in the vicinityAttempt to annoy someone elseExcessive noise or silenceRecent change to environmentImmobile person sitting signalling discomfort – e.g. sitting in sunlight or in a draughtRejection of current surroundings | |
| Table 2.2 The common biopsychosocial causes of sexual disinhibition | |
| Sexual disinhibition | |
| BiologicalFrontal lobe deficits, resulting in disinhibitionParkinson’s medication resulting in hypersexualityExcess use of alcohol, resulting in disinhibitionHigh libido | PsychologicalBoredRestlessMisidentifying other people as one’s partnerBelieving one is young, and sexually availableMisinterpreting intimate personal care activities as a sexual advanceMethod of reducing stressDisinhibitionA reliable method to be removed from a fearful/unwanted situation |
| Social and environmentalLots of members of opposite sex in the environmentAvailability of bedroomsConfused members of the opposite sex making advancesLooking for companionshipLooking for comfortSeeing other people in their night-wear | |
| Table 2.3 The common biopsychosocial causes of aggression | |
| Aggression – one needs to observe such behaviours carefully as the label is very subjective. Many aggressive acts are the products of perceived threat and/or anxiety. Despite the destructive aspects, aggression indicates the person with dementia still feels things are worth fighting for. If she loses this self-belief, she may become depressed. | |
| BiologicalFrontal lobe deficitsHead injury leading to disinhibitionDrug induced restlessnessUnderlying physical conditionsInfectionEffects of excess use of alcoholParanoid delusions requiring someone to defend themselvesHallucinations requiring someone to defend themselvesPain reducing threshold of agitationFending-off contact due to bodily painTemperamentSensory deficits | PsychologicalRestlessFrustration at not being able to communicate wellFrustration at not being understoodPerson thinks her rights are being infringedPerson feels patronised (treated like a child)Person thinks she is being unnecessarily rushed and harriedPerson thinks not being listened toPerson feels embarrassed during personal care tasksPerson thinks her personal space is being invadedPerson thinks not being allowed to use her existing abilities and skillsCo-existent mental health problemsDisinhibition |
| Social and environmentalCultureMisidentifying other peopleMisperceiving other people’s intentionsInterpersonal over-stimulationA particular carer is not acceptable to her (e.g. due to age, gender, race or colour)Person does not like being touched by someone elseSetting is unacceptablePerson not being allowed to leave the buildingPerson made to feel incompetentPerson does not like the restrictive rules and regulations being imposedCaregivers providing inconsistent approachesOver-stimulation (noise, lights)Setting is too hot or coldWeather is very warm and close | |
| Table 2.4 The common biopsychosocial causes of stripping | |
| Removing clothes (stripping) – environmental features (weather, room temperature), body temperature and cultural aspects play important roles with respect to this behaviour. | |
| BiologicalHypothalmus – temperature control impairedFrontal lobe deficits, resulting in disinhibitionSensitive skinDrug-induced rashDrug-induced restlessnessParkinson’s medication resulting in hypersexualityUnderlying physical condition – resulting in feel hotHigh temperature due to infectionProstate problemsExcess use of alcohol, feeling flushed and/or disinhibitedConfusing night with day, thus undressing to prepare for bed | PsychologicalBoredRestlessDislikes the clothes given to wearProtesting that clothes given are not their own clothesDisinhibitionLifestyle preference (never worn many clothes)A method to be removed from a fearful situation |
| Social and environmentalCopying other peoplePreparing to engage in sexual actsCulture does not wear many clothes, or does not regard nudity as a problematic issueSetting is too hotWeather is very warm and closePerson’s room is very sunnyPreparation for going to the toiletClothes are irritable, itchyIll fitting clothes – too tight or looseUnderwear too tightChairs with surfaces that make people prone to sweating | |
| Table 2.5 The common biopsychosocial causes of walking with/without purpose | |
| Walking with/without purpose (wandering) – there are many positive aspects to this activity (exercise, stress reduction, etc.). Hence, it is often appropriate to provide safe walking areas, rather than deny people the opportunity to engage in the behaviour. | |
| BiologicalDistraction from pain and discomfortRelief physical discomfort (back pain, constipation)Drug-induced restlessnessInfection induced confusionSearch for food or water due to hunger/thirstSundowningMemory difficulties, resulting in people forgetting their original intentionsCognitive disorientation | PsychologicalTo reduce anxiety or fearLonelinessBoredomOver/under stimulatedCoping with distressExerciseEnjoymentTo promote own sleepTo give a sense of controlContinuing a life-long habitLow moodTo explore surroundings due to memory and orientation difficultiesWalking after a meal |
| Social and environmentalSearching for carerSearching for objectsSearching for family membersSearching for toiletSearching for own roomEnables someone to meet othersPoor signageConfused layout in settingFinding way to access gardenFinding way out of buildingOrientate oneself to the surroundingsCurious about environmentCues from light cycle (day/night) | |
| Table 2.6 The common biopsychosocial causes of absconding | |
| Absconding | |
| BiologicalDisorientationSuspicious and paranoid about surroundingsMisperception that environment is hostile | PsychologicalUpset at having liberty taken awayFear of staying in a strange placeFear of being around confused peopleLooking for comfort and securityTime displacement, thinking younger and person with care responsibilities |
| Social and environmentalEnvironment is confusingEnvironment is dirtyEnvironment is smelly, too hotEnvironment is under-stimulatingSearching for family membersSearching for objectSearching for own roomEnables someone to meet othersPoor signageConfused layout in settingUnable to make friends in settingFinding way to access gardenFinding way out of buildingOrientate oneself to the surroundingsCurious about environmentCues from light cycle (day/night) | |
Biopsychosocial causes of a range of BC
Tables such as Tables 2.1–2.6 above are helpful in providing ideas for treatment, and show the commonality of causes across the various types of BC. For example, pain may manifest itself behaviourally in numerous presentations from shouting to walking, and aggression. Thus to help clarify the specific causes of a BC, it is often beneficial to try to identify the idiosyncratic beliefs that may be driving the behaviour (e.g. I need to go home to collect the kids from school). This issue is discussed in more detail below.
ROLE OF BELIEFS
One of the chief ways NCBT’s treatment differs from other methods in the field is its emphasis on the role of cognitions (thoughts and beliefs). Indeed, it is my opinion that beliefs play a key role in determining how disruptive a BC can become. It is relevant to note that even when clients’ thinking becomes incoherent and muddled, one can often identify key beliefs that trigger and sustain their behaviours. Table 2.7 provides some examples of common motivating beliefs; note, they are described within the NCBT categorisation discussed in the first chapter in Table 1.2.
