Escalation vs Overstimulation

As a program director at UPMC's Western Psychiatric Hospital, I provided education in the form of presentations and lectures on Escalation. The name of the presentation was something along the lines of "Positive Approaches in Crisis Management and De-Escalation Training." The model of escalation was built, not surprisingly, from the Information Processing Model (IPM) popularized in Cognitive Behavior Therapy (CBT).

IPM is a cognitive processing model, focused on 4 cognitive processing steps: thoughts, emotions, behavioral decisions and learning from consequences. Thoughts shape emotions, emotions influence behaviors, behaviors lead to consequence, which we ostensibly learn from, and the consequence in itself is a new event.

However, you can imagine this does not apply to individuals with Major Neurocognitive Disorders (dementia, or NCD). A Neurocognitive disorder, by definition, implies deficit(s) to one or more cognitive domains to the degree that it impairs safety in remaining independent. These cognitive domains include:

• Complex attention

• Executive function

• Learning and memory

• Language

• Perceptual-motor

• Social cognition

If there is a notable deficit to a cognitive domain, we would not expect the individual to perform well with cognitive demands in the world or cognitive tasks in processing that hinge upon that specific domain. If we expect this individual to be thoughtful in their response to a stimuli/event, and be able to process this after a problematic behavior, we are barking up the wrong tree. We will be frustrating (to ourselves and the individual) and ineffective nearly ubiquitously.

So how do we understand behaviors if not through the information processing model? We conceptualize and understand this through the phenomenon called the Stimulus-Bound Reflex (SBR). Several conditions, including NCD affect executive functioning (a cognitive domain) to the degree the individual has difficulty or inability to filter stimuli, becomes easily overwhelmed or overstimulated, and responds reflexively rather than based upon cognitive processing including thought, emotion, behavioral decision making, and contemplating and learning from consequences.

The SBR occurs in various populations. The fusiform gyrus is the region of the brain involved in visual expert recognition. It connects the cognitive/verbal processing in the temporal lobe to the visual processing in the occipital lobe, and, when damaged, results in prosopagnosia (facial blindness). It is designed to help us recognize faces, as well as other learned expert recognition such as an expert chess player who is able to look at a board and immediately know who will win. Babies are attuned to our face and facial expressions, including anything that obstructs it. Any parent can recall their baby grabbing their glasses, hats and earrings: it is a stimuli-response process (SBR). They see it, so they grab it.

Individuals with autism are often stimulus bound, particularly when overstimulated and overwhelmed. Difficulty stimuli filtering and sensory processing are hallmarks of this condition. This also occurs in severe psychosis and mania. Consequently, there are vital clinical scenarios in which understanding non-cognitive behavior models are remarkably important. This could be a pervasive developmental treatment facility, outpatient work with an individual with autism, a memory care nursing home unit, or with a notable portion of inpatients. Here is a model comparing overstimulation to escalation in IPM:

The common factors are green - input and output, while the cognitive processes are demarcated in red. While cognitive processes may be occurring despite someone being stimulus-bound (and in the overstimulation model), they are often not significant influences in the person's behavior, nor accessible to us as care providers such as through conversation / clinical interview, and learning may not be encoded into long-term memory. Consequently, what we have the most influence over is the stimuli - the surrounding environment. To change the behavior, change the environment.

This is likely most relatable in the context of autism: discussion of overstimulation for this population is common and we have almost certainly all seen an individual with sensory processing issues wearing headphones or ear muffs in loud places. Individuals with dementia may require reductions in overstimulation or removal of stimuli that triggers unsafe behavioral responses. However, we have to be cautious about dampening sensitivity to stimuli as individuals with dementia already have reduced sensory functioning (numbness in extremities, reduced vision, poor hearing) and this is associated with worsened cognitive functioning. Reduced access to stimuli that sets circadian rhythms is thought to worsen sundowning and nighttime behavioral problems like wandering instead of sleep, or wake-sleep reversal. Individuals in memory care may have little access to sunlight - many memory care facilities are described like a cave. There may be unintentionally dim lights or intentionally dimmed lights to reduce overstimulation and encourage calm, but this can increase falls in addition to the above described risks (worsening cognitive function by further dampening senses or impairing circadian rhythms). We may want to provide a low-light living room type space for calming, but avoid dimming the entire unit. Soft, calming or uplifting, familiar music can be powerfully influential - we typically played oldies and motown on the Integrative Health and Aging program (IHAP).

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Interventions

• Lights:

  • Bright lights for vision and circadian rhythms, outdoor time

  • Low light areas for calming, but remove fall risks

• Sound:

  • Soft, upbeat music. Games like Name That Tune, sing-along, etc.

  • Quiet spaces or ear muffs /headphones for temporary overstimulation

• Sensory based interventions:

  • Identify individuals preferred sense(s) and activities

  • Tactile tend to be common: folding linens, petting stuffed animal, baby doll, play-dough or clay, coloring

  • Olfactory: scented oil, hand cream, cooking, flowers

  • Taste: have preferred snacks available

• Reduce fall hazards and overstimulation (a patient saw brown bags outside the locked doors through the window and thought they forgot their groceries - removing the bags solved the problem).

• Don't scold or raise voice, self-care to avoid caregiver burden, tag-out when needed

• Reminiscence: old pictures and items, old movies and music, old books or coffee table picture books

• Have clear signs or picture/image based signs and communication, PEC boards