Sexual Disinhibition and Social Skills: Behavioral Interventions for Persons with TBI
by Michael P. Mozzoni, PhD/BCBA-D, Austin Errico, PhD & Tina M. Trudel PhD
Introduction
The issue of sex difficulties following an acquired brain injury (ABI) can be a complex and uncomfortable subject matter for family members and many professionals. As a result, changes in sexual activity following an ABI or traumatic brain injury (TBI) are frequently omitted as an integral part of a person’s rehabilitation plan. This shortfall is unfortunate given the importance of sexual intimacy to the human condition, as well as the viable options available that could potentially assist individual survivors and their partners who would like to enjoy a satisfying sexual life. This article examines two techniques that demonstrate relatively easy interventions that foster behavior change in persons demonstrating hypersexuality following TBI. The article focuses on two case studies following treatment intervention. Hypersexuality is a rare but well recognized condition following brain injury. It has been associated with dysfunction of the hypothalamus, the temporal lobes and the frontal lobes. Hypersexual behaviors include explicit verbalizations, exhibitionism, non-consensual touching/groping, high frequency masturbation, arousal to mild sexual content/stimuli, over-selectivity to intimate apparel and obsessive sexual thoughts, to mention but a few of the more salient aspects. Hypersexual behaviors present a danger to the person and others. Non-consensual sexual behaviors are not tolerated within society, often resulting in legal consequences. Persons with a brain injury who grope a passerby may find themselves arrested and charged as a sex offender/ predator often requiring them to register with their local police department, and including their name on the national registry of sex offenders. The Merriam-Webster dictionary defines disinhibition as: a loss or reduction of an inhibition (MWD online). Disinhibition and impulsivity are functionally equivalent. While clinicians use terms like these, law enforcement uses terms like “rape, assault, and sexual predation� (Strauss 2005). Disinhibition syndromes, ranging from mildly inappropriate social behavior to full-blown mania, may result from lesions to specific brain areas. Several studies of persons with closed head injuries, brain tumors, stroke lesions, and focal epilepsy have demonstrated a significant association between disinhibition syndromes and dysfunction of 22 BRAIN INJURY PROFESSIONAL
orbitofrontal and basotemporal cortices of the right hemisphere. The orbitofrontal and basotemporal cortices may selectively inhibit or release motor, instinctive, affective, and intellectual behaviors elaborated in the dorsal cortex. Thus, dysfunction of these areas may result in disinhibited behaviors. (Starkstein & Robinson 1997; Grafman, et.al. 2002; Spinella, 2007). Many of the same cortical and sub-cortical structures mediating inhibition and impulsivity (frontotemporal regions) also mediate social skills, sexual behaviors and recognition of emotion (Neumann et. al. 2007). Wikipedia defines social skills as: skills a social animal uses to interact and communicate with others to assist status in the social structure and other motivations. Social rules and social relations are created, communicated, and changed in verbal and nonverbal ways creating social complexity useful in identifying outsiders and intelligent breeding partners. The process of learning these skills is called socialization (wikipedia.org). Social skills are extremely complex and subtle. The speaker must attend to the listener to glean verbal as well as non-verbal feedback. Unfortunately while there are many social skills training programs, few are effective in transferring competence (knowledge of social rules, roles and routines) and performance (acting in real world social circumstances) outside of the training sessions (Ylvisaker & Feeney, 2001). In fact, Rolls (2000) notes that disinhibition associated with injury to the ventral prefrontal region of the brain interferes with learning from consequences, which is a key component of behavioral interventions. This may explain why as a diagnostic group, people with TBI respond better to antecedent based interventions than other groups. Hornak et al. (1996) found that people with ventral medial frontal lobe damage had poor social behaviors. They suggest that when there is damage to the prefrontal cortex, the person may not only have difficulty identifying emotions in others but they may also have difficulty identifying their own emotions.
Two case studies
Two females who presented symptoms of sexual disinhibition and resided in a residential rehabilitation program were participants in this study. Both displayed high rates of sexually disin-