Disinhibition

In psychology, disinhibition is a lack of restraint manifested in disregard for social conventions, impulsivity, and poor risk assessment. Disinhibition affects motor, instinctual, emotional, cognitive, and perceptual aspects with signs and symptoms similar to the diagnostic criteria for mania. Hypersexuality, hyperphagia, and aggressive outbursts are indicative of disinhibited instinctual drives.

Clinical concept

According to Grafman et al. (1) “disinhibition” is a lack of restraint manifested in several ways, affecting motor, instinctual, emotional, cognitive, and perceptual aspects with signs and symptoms e.g. impulsivity, disregard for others and social norms, aggressive outbursts, misconduct and oppositional behaviors, disinhibited instinctual drives including risk taking behaviors and hypersexuality. Disinhibition is a common symptom following brain injury, or lesions, particularly to the frontal lobe and primarily to the orbitofrontal cortex. The neuropsychiatric sequelae follow 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, lack of control over one’s behaviour to the full-blown mania, depend on the lesions to specific brain regions. 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, and spatial memory, motoric, instinctive, affective, and intellectual behaviors.

Disinhibition syndromes have also been reported with mania-like manifestations in old age with lesions to the orbito-frontal and basotemporal cortex involving limbic and frontal connections (orbitofrontal circuit), especially in the right hemisphere. Behavioral 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, hyperactive/impulsive subtype have a general behavioural disinhibition beyond impulsivity and many morbidities or complications of ADHD, e.g. conduct disorder, anti-social personality disorder. substance abuse and risk taking behaviours are all consequences of untreated behavioural disinhibition.

Associative learning concept

Within the realm of classical (Pavlovian) conditioning, disinhibition is a fundamental process of associative learning characterized by the recurrence of a conditioned response after extinction trials have eliminated said response elicited by the presentation of a novel stimulus. The following process best illustrates this form of disinhibition:

An organism undergoes some series of classical conditioning trials until the conditioned stimulus reliably elicits a conditioned response. At this time, the organism then undergoes extinction trials until the conditioned stimulus no longer reliably elicits the conditioned response. Disinhibition occurs when, after these extinction trials, a new, novel stimulus is presented to the organism and at which time the organism again begins to show the previously extinguished conditioned response. This phenomenon is not to be confused with spontaneous recovery, though the concepts seem similar.

Disinhibition is the temporary increase in strength of an extinguished response due to an unrelated stimulus effect. This differs from spontaneous recovery, which is the temporary increase in strength of a conditioned response, which is likely to occur during extinction after the passage of time. These effects occur during both classical and operant conditioning.

Colloquial usage

Clinical terms sometimes gain a broader usage and meaning in society outside of their original technical definition. The concept of disinhibition is being applied with some regularity in news articles as an explanation for how youth communicate differently when using the media of instant messaging, text messaging, and posting content on social networking sites. Because technology may provide a perceived buffer from regular consequences and an actual buffer from traditional social cues, people will say and do things through technology that they would not say and do face-to-face.

Further information

Individuals who show disinhibited behaviour tend to have this as part of a cluster of challenging behaviours including verbal aggression, physical aggression, socially inappropriate behaviour, sexual disinhibition, wandering, and repetitive behaviour.

Disinhibited behaviour occurs when people do not follow the social rules about what or where to say or do something. People who are disinhibited may come across as rude, tactless or even offensive. For example, a person with a brain injury may make a comment about how ugly another person is, or a person with dementia may have lost their social manners and look as though they are deliberately harassing another person.

Sexually disinhibited persons may inappropriately flirt with someone or make sexual comments. A person might expose themselves such as taking off part or all their clothes in public. They may unexpectedly fondle themselves or masturbate in public. They may touch other people on their face, arms, legs, buttocks or genitals.

The reasons why these behaviours may occur include:

• Brain-related changes that occur from dementia; damage to the brain such as in brain injury, usually the frontotemporal or obitofrontal areas, i.e. the frontal lobes (part behind the forehead)
• Difficulty thinking about the consequences of their behaviour
• Misinterpreting social cues (e.g. someone's politeness might be read as the go-ahead for touching); poor social judgement
• Being unable to communicate in an appropriate way
• Response to factors in the environment, e.g. a young woman standing very close to an elderly demented man might touch her legs without telling her why (such as because she's changing his bed clothes)
• Being confused about where the sufferer is (e.g. thinking he or she is in the bathroom and starting to undress), who they are interacting with (e.g. care home staff may be confused with the sufferer's wife or girlfriend and then be touched)
• Feeling lonely
• Discomfort such as being too hot or cold may lead to undressing, or a urinary tract infection may lead to touching one's own genitals
• Provocation

Treatment approaches

Positive Behaviour Support (PBS) is a treatment approach that looks at the best way to work with each individual with disabilities. A behavioural therapist conducts a functional analysis of behaviour which helps to determine ways to improve the quality of life for the person and does not just deal with problem behaviour.

PBS also acknowledges the needs of support staff and includes strategies to manage crises when they arise. The following model is a brief guide to staff to remind them of key things to think about when planning support for a person with disabilities. There are two main objectives: reacting situationally when the behaviour occurs, and then acting proactively to prevent the behaviour from occurring.

Reactive

Reactive strategies include:

• Redirection: distracting the person by offering another activity, or changing the topic of conversation. 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
• Crisis management

Proactive

Proactive strategies to prevent problems can include:

• Change 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).
• Teach a skill: These 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 behaviour and ignoring the specific undesirable behaviour (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 behaviour occurs, assertively in a nonjudgemental, clear, unambiguous way provide feedback that the behaviour 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". Then re-direct to the next activity. Any subsequent behaviour ignore. Then generally, as almost all behaviour is communication, understand what the behaviour is trying to communicate and look at ways to have the need met in more appropriate ways.

See also

• Boldness
• Frontotemporal dementia
• Online disinhibition effect
• Orbitofrontal cortex

External links

• The Online Disinhibition Effect
• Social Behaviour In Cyberspace
• External Inhibition & Disinhibition