Fatigue and lack of motivation
Fatigue and a disorder of motivation, adynamia, typically arise after injury to the frontal
lobes, particularly in the dorso-lateral area.
Fatigue is a very common outcome after acquiring a brain injury due to the many tiny sites of damage throughout the
brain. It is different to the yawning and sleepy feeling of normal fatigue. This type fogs the mind, drains all energy,
dampens movement and sleep may do little to reduce it.
People with adynamia will experience loss of drive, indifference and placidity. There is usually
slowed mental function, a marked decrease in ideas and activity is rarely self-initiated. There is often not only a
verbal reminder needed to start a task, but further reminders required throughout the task.
It is easy to see how family members could get frustrated in these situations unless they
fully understand the impact of adynamia.
The activities that are normally automatic will often require effort after the injury. These activities can be concentrating,
warding off distractions, reading for meaning, doing mental calculations, monitoring ongoing performances, planning the
days activities, attending to two conversations at once or conversing with background noise. The huge effort involved for
a brain injury survivor means they often need to sleep in the early afternoon due to the mental exhaustion involved in
getting through the morning.
Characteristically, providing their sleep has not been disturbed, the person starts the day with some feeling of energy.
Then, fairly suddenly, often they say like a curtain falling down, they find they are struggling to keep going; and can’t
make sense of what they’re doing. If they recognise this warning and rest for an hour or two they may recover and be
able to start again for another period. If they neglect the warning and go on working until they can cope no longer they
bring on a state of severe fatigue which will stop them doing anything productive for the rest of the day; often it will
persist and prevent useful work the next day, or even longer.THE LOST ART OF LOOKING INTERESTED
In social interaction the person may not appear to be interested in the conversation, with
dull responses to people or given situations. Social skills are exactly that—skills. But
because they become second nature for most adults it is hard to accept that someone with
a brain injury may be struggling to keep up, pay attention, provide appropriate visual cues,
analyse what was said, think of a response AND look interested at the same time.LACK OF UNDERSTANDING
A brain injury is often cal ed the hidden disability. Fatigue and adynamia are good
examples of this. Often a person will have no visible scarring so all their employers, family
and friends may see is an apparently lazy person who enjoys an afternoon nap, gets upset
when you give them a few tasks and doesn't give affection or take interest in what you say
The cruel irony of the situation is that the survivor may never have worked this hard to
accomplish tasks, reacquire their social skil s or achieve the simplest of goals. When the
injury is 'invisible' it may be crucial for employers, family and friends be ful y informed of
adynamia to begin the process of understanding its devastating impact.
Comments by the family or pressure at work can make the situation worse. It is difficult for others to understand the
limitations imposed by the fatigue and they can encourage or embarrass the patient into continuing in spite of it. When a
patient who has been improving starts to regress, this sort of situation will often be uncovered.TASK ANALYSIS
Task analysis is one possible strategy to combat adynamia, or problems with motivation. Tasks are broken into individual
sequenced steps and formed into a checklist. Each step is then ticked as it is completed. In this way beginning,
completing and following through on a task is much easier.
This reduces fatigue as it minimises the need to plan, organise, decide, prioritise, remember and put things in sequence.
These are only some of the cognitive issues required to say, cook an omelette. The person with adynamia can be
exhausted by these tasks before they've even opened the kitchen door.
Task analysis re-establishes the routines in our activities of daily living. With the use of checklists and lots of practice it
can eventually make a great improvement in terms of drive and motivation.
The ingredients for rebuilding these automatic habits are the three P's: Plan, Practice and Promotional attitude. The
result is rehabilitation, or removing obstacles to independence, and systematic achievement of incremental goals in
desirable life areas.
Once you have goals in place, try building your motivation by:
• Telling people about the goal to confirm personal commitment
• Monitoring progress towards the goal by noting signs of improvement
• Developing a system of external rewards to reinforce personal effort
• Developing a routine which allocates time towards the goal
• Identifying people to provide support and encouragement.SOCIAL SKILLS
A logical place to start here is to find out how social interaction has been affected by adynamia. Usually family and close
friends can be relied upon to give you their honest impression if you insist on your need for accurate feedback. This
should give you an idea as to which areas you need to work on, such as poor listening, or appearing vague or
uninterested. Some therapists can assist in relearning skills through practice and repetition in functional situations.
Alternatively you could buy books on effective communication and work on these in day-to-day situations.
In some ways the brain can be likened to a four lane freeway. The heavy traffic may be moving along rapidly but close
just one lane and suddenly there is a traffic jam. The same can happen with your social interaction. You may need to
avoid group situations or distracting environments as the ensuing 'traffic jam' will overload your ability to communicate
Sleep disorders are common after a brain injury. Lack of sleep will greatly multiply all the existing problems faced by a
survivor. Sleep can also have an impact on recovery so it is crucial to sleep well, and seek help if this proves difficult.SHOULD I TELL PEOPLE ABOUT FATIGUE OR ADYNAMIA?
In some cases it can be best to inform people about problems with fatigue. Given the right information, family and true
friends should be concerned enough to understand your difficulties and make allowances. This also gives you the
freedom to say you are getting fatigued and need to take a break. When they understand adynamia they should realise
that it is not their conversation putting you to sleep!
Sometimes a brain injury can result in difficulties in making social judgements. People can be too open and trusting
particularly after a frontal lobe injury. If you are wondering whether you should tell someone about your brain injury and
how it has affected you, it may be best to discuss it first with a trusted friend or family member.
Please note that these articles remain the copyright of the Brain Injury Association of Queensland. These articles may be
reprinted in newsletters, magazines and journals of your Association provided no changes are made to the text and the
acknowledgement at the end of the article is included.
This is one of over 100 fact sheets on brain injury available at www.biaq.com.au/facts.htm and reprinted with the
permission of BIAQ.