‘Behavioural’

This is a term you sometimes hear on the wards, as in, ‘She is very behavioural,’ or, ‘The minute he saw me he started shouting, it’s all behavioural…’

This to me is interesting, particularly in relation to physical or mental health or both.

Mostly this is said about older people who act in a way that is not consistent with their underlying disease – what I mean, is, say someone is crying when you approach them, they may say their back is sore, or their neck, or they feel sick or anxious, the complaint doesn’t really matter.

In medicine, when someone has a symptom that is associated with a certain disease process, that’s OK.

Arthritis – sore hip – OK, ulcer – stomach pain – OK, epilepsy – collapse – OK.

If the symptoms and the signs (what is found on examination) are consistent with what is in the text-book, things are cool. It might be incurable, but at least your situation is grounded in anatomy, physiology and logic.

Behavioural is when cause and effect break-down:

Normal hip (or knee, or back) – sore hip; where do you go? Or, collapse – when the doctor approaches, hyperventilation when family depart.

All of this is sometimes, after a lot of effort and careful balancing described within the context of functional illness – that is, symptoms that have a cause that is not physical but psychological.

In this model,

anxiety – sore back – OK or, depression – collapse – OK.

It depends who is examining or assessing you. In some circumstances, you might be considered to be ‘putting it on’ – malingering; in another, one that is perhaps more informed, your experience is taken on face-value and the cause doesn’t really matter – psychological or physical, the pain is the same.

Mostly, when behavioural is used in relation to my patients, this is someone who is older who has an underlying diagnosis of dementia or delirium, but, who does not have a physical abnormality to account for their symptoms.

It is akin to functional, yet, in the world of acute hospitals this is not a widely accepted or understood term, instead therefore, behavioural.

Yet, when you consider it, when you take either a physical or existential microscope and look inside, there is usually something wrong, something amiss that explains the behaviour. In the case of someone who has dementia, this can be an inability to either comprehend the situation or express their emotions. Such that,

Distress – lie on ground, anxiety – collapse.

I guess my point is that specifically, if we were better-informed – perhaps more enlightened or knowledgeable, we would understand that when someone has a psychological symptom, whether there is anything physical underlying or not is hardly the point. To me, it is just that we can’t see with enough detail or clarity.

Stroke – altered behaviour, is considered OK, that is brain-damage, but, early dementia – behaviour is not; sometimes, and this is when it is most difficult, a person seems to be fine, they are getting-on with their lives, yet, in certain situations, for example, during hospitalisation, the behaviour becomes apparent.

We could take one approach and consider that the person is inducing the symptoms, trying to con us into being helpful or sympathetic, or, you could take the symptoms on face-value.

Within this there is a 21st Century tension. As we are able to look in incredible detail at the insides of our bodies using CT, MRI and functional imaging, people consider that we must have a window into all maladies. This leads to more and more sophisticated and complex investigations which potentially lead to false-positives and increased anxiety.

We can see which part of the brain lights-up or not when you are thinking of fish-fingers or you smell avocado, as to the individual neurones, the quantum waves that constitute thought, idea, emotion or inspiration we have a long way to travel.

Where does all of this take us?

It takes us to a point where we must consider all symptoms as they are. For some we will arrive at a straightforward explanation – fall – fracture – pain; perhaps the substance of a material world, at other times we will have just ‘pain’.

Acknowledging that pain is pain no matter the cause is central.

Just as with suffering, it is not something that can be measured and compared, it isn’t absolute, it is relative like everything else in the universe, and, the only way to approach this proportionately is with empathy and compassion, try to understand, and when you don’t understand accept your or the system’s limitations, don’t blame the messenger. Celebrate them as they are providing an insight into a world that is yet to be discovered.

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