Aggressive Behavior After Brain Injury

Clinical Correlates Of Aggressive Behavior

Of the 89 patients who suffered a traumatic brain injury, 30 of them met the aforementioned criteria for the presence of significant aggressive behavior during the first 6 months after the traumatic episode. The remaining 59 patients constitute the nonaggressive group.

The background characteristics of the two groups are summarized in . There were no significant differences between the aggressive and the nonaggressive groups in age, gender, race, years of education, socioeconomic status, or history of anxiety disorder. In addition, the frequencies of hypoxia and hypotension, the two most significant complications contributing to secondary brain damage, were not significantly different between the aggressive and the nonaggressive groups . Patients in the aggressive group had a significantly higher frequency of a history of a mood disorder , alcohol abuse , and substance abuse than those in the nonaggressive group. However, there was no significant difference between the two groups in the frequency of alcohol or substance abuse during the month preceding the onset of aggression. In addition, five of 30 TBI patients with aggression had a history of legal intervention for aggressive behavior, compared with one of 59 nonaggressive TBI patients .

History Of Mtbi Among The Study Participants

Among the mTBI without reported history of LOC , 78.1% reported only one mTBI, 13.7% reported only two, and 8.3% reported three or more mTBIs. Of the total mTBI group reporting mTBI with LOC , 84.5% reported one mTBI with LOC, 10.9% reported two mTBIs with LOC, and 4.5% reported three or more mTBIs LOC.

Get A Family Member To Help

If youre comfortable with it, have trusted family members or caregivers monitor your overstimulation. They might pick up on cues that you dont notice, like getting a glassy-eyed look. They can tactfully remind you to take care of yourself and destimulate.

If youre a caregiver, just be aware that unsolicited interventions may not help the situation. For example, someone who usually would be comforted by a touch on the shoulder might get worse due to the additional sensory input. Its important to talk to your loved one about what helps them or hurts them in the moment.

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Data Handling And Analysis

It will be the responsibility of the investigator as delegated to ensure the accuracy of all data entered in the CRFs. The delegation log will identify all those personnel with responsibilities for data collection and handling, including those who have access to the trial database.

Data will be collected using paper CRFs and then transcribed onto a Microsoft Access database that is created prior to the start of the trial. Data monitoring will be carried out according to the trial-specific monitoring plan. This details the quality control checks to be carried out during site visits and when checking the database. All serious adverse event and primary outcome data will be checked and a random sample of the secondary outcome data. The database will be stored on a network drive at Imperial College London, which is backed up daily. Data will only be input onto the database at Imperial College London from a computer owned by the organisation that has access to the network drive.

At the end of the trial, data monitoring will be completed and the database locked so that no further data entry is possible. At this point the data will be given to the trial statistician along with the randomisation list stating whether participants were allocated to arm A or arm B. The data will be analysed without knowledge of which arm relates to the active trial medication.

Aggressive Behavior After Head Injury

Traumatic brain injury is a complex issue for a variety of reasons. First, many cases of TBI go undiagnosed for months or even years. Since patients with head injuries often times have other injuries, the brain trauma may not receive the attention it deserves.

Another problem with head injury is that it often results in psychological symptoms that can complicate the diagnosis and treatment. Traumatic brain injury can result in depression, changes in personality, anxiety, paranoia, or apathy. One of the most frustrating and challenging symptoms is aggression.

The authors of a current study on aggression after brain injury stated the problem succinctly:

Associations between TBI and neuropsychiatric disorders have been recognized for many years. Aggressive behavior is one of the most socially and vocationally disruptive consequences of these neuropsychiatric disorders. Aggression endangers the safety of patients, families, and caregivers. It may prevent patients from receiving the care that they need and disrupt their rehabilitation process. Estimates of the frequency of aggressive behaviors during the acute period after TBI have ranged from 11% to 96%.

In this study, the researchers assessed 89 patients with TBI and 26 patients with multiple traumas, but without TBI. All of the TBI patients in the study had post-traumatic amnesia that lasted at least 30 minutes.

Clinical Implications

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Concealment And Unblinding Procedure

Trial medication will be identified by a randomisation code that corresponds to either risperidone or placebo, labelled during manufacture and bottling of the capsules. This will keep the patients, clinicians, carers and researchers blind to the allocation of active drug and placebo. Three bottles of trial medication will have the same randomisation code to allow sufficient supply for one participant to complete 84 consecutive days. Trial medication will be supplied to site pharmacies in blocks sufficient to provide medication to six participants. There will be a 24-h telephone number available for the clinicians and research team if the randomisation code needs to be broken. This information will help to design pharmacy arrangement and associated logistics for the full RCT which is likely to involve a large number of centres.

Causes Of Aggressive Behavior After Brain Injury

After a head injury, survivors can experience a variety of secondary effects. Depending on the areas of the brain affected, these effects can be physical, cognitive, and/or behavioral.

For example, the frontal lobe is a large area of the brain that plays a crucial role in reasoning, problem-solving, and impulse control. When the frontal lobe sustains damage, it can impair these behavioral skills which can lead to aggressive and irrational behavior.

Studies show that 30% of frontal lobe injury survivors experience aggressive behavior, and it most commonly appears during the first few weeks after the initial injury known as the acute phase. According to the Rancho Los Amigos Scale , aggression can be characterized as a normal part of the recovery process.

In this early stage of recovery, survivors may also experience post-traumatic amnesia or disinhibition. Individuals with post-traumatic amnesia often struggle with memory and exhibit uncharacteristic behaviors. Similarly, individuals with disinhibition lack the ability to control inappropriate behaviors often leading to risky behavior and poor .

Many survivors are also at risk of entering a temporary state of delirium, where they have minimal to no control over their emotions and behavior. This delirium is often a symptom of frontal lobe damage.

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Peer Support And Other Resources

Remember, not all help comes from professionals! You and your family may benefit from the following:

• Support groups: Some support groups are for the person with TBI, while others are for family members, and some are open to everyone affected by TBI. Information about support groups may be found through TBI organizations, rehabilitation facilities, and social media, among other places.
• Peer mentoring: A peer is a person who is currently living with a TBI. A peer can offer support and advice to others who are new to TBI and dealing with similar problems.
• Brain Injury Association : Reach out to your local chapter for resources, including training and resources for caregivers and family members.
• Find someone to talk to. Reach out to a friend, family member, member of the clergy, or someone else who is a good listener.

Tips For Coping With Aggression After Tbi

If you know someone who is experiencing aggression after TBI:

Respond, but dont react. When someone is having an aggressive outburst, reacting with anger or irritability only worsens the aggression. Do your best to respond to the person calmly and gently, speaking softly, but clearly, while ensuring a safe environment.

Be alert for aggression triggers and try to minimize or remove them. Triggers may be related to the environment , people involved in the persons care , or something the person with aggression is doing or not doing .

Identify behavioral patterns of aggression. Channel the aggressive energy into healthier, safer activity. For example, if the person with aggression likes to throw things when he gets aggressive, provide a soft, squishy ball or a pillow and teach him to squeeze it when he feels angry. Teach him this behavior when he is calm and willing to listen and learn.

Discuss the consequences of aggressive behavior. Pick a time when the person is calm, to discuss his behavior and state specific consequences of such behavior. Be consistent, because inconsistent responses are confusing and can interfere with learning behavioral change.

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Ethics And Regulatory Requirements

The sponsor will ensure that the trial protocol, Study Information Sheets, Consent Forms, GP letter and submitted supporting documents have been approved by the MHRA and a main REC prior to any patient recruitment. The protocol and all agreed substantial protocol amendments will be documented and submitted for ethical and, where necessary, regulatory approval prior to implementation according to sponsor-specific Standard Operating Procedures .

Before the site can enrol patients into the trial, the Trust Research and Development for the site must grant written permission. It is the responsibility of the PI at each site to ensure that all subsequent amendments gain the necessary approval. This does not affect the individual clinicians responsibility to take immediate action if thought necessary to protect the health and interest of individual patients. All PIs will be required to have an up-to-date Good Clinical Practice training certificate.

Within 90 days after the end of the trial, the CI/sponsor will ensure that the main REC and the MHRA are notified that the trial has finished. If the trial is terminated prematurely, those reports will be made within 15 days after the end of the trial. The CI will supply the sponsor with a summary report of the clinical trial, which will then be submitted to the MHRA and main REC within 1 year after the end of the trial.

Cutting Edge/ Emerging And Unique Concepts And Practice

For agitation and aggression, there have been reports of the successful use of electroconvulsive therapy. Complementary and alternative therapy modalities, including massage therapy and essential oils, have also been implemented.24 However, these trials have not been large or generalizable enough to be widely applied. Additional research is needed.

In a small study, neuromodulation with repetitive transcranial magnetic stimulation has shown benefit as a treatment modality for apathy in patients with Alzheimers disease.33 More research is needed though to determine if neuromodulation is beneficial in other disease processes that result in apathy.

Providing care via telehealth or other virtual means can be helpful for people with brain injuries and their families. As technology becomes available, patients and clinicians become more comfortable using it, and other logistics and barriers are addressed, this new way of delivering care may become even more common. Neuropsychiatric sequelae, including aggression, can be assessed. Cognitive behavior therapy and related interventions, along with family education, can be provided. This may help people with chronic effects of brain injury, who may have difficulty coming in to the clinic regularly, access essential and beneficial care. 34

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Understanding The Triggers Of Aggressive Behavior After Brain Injury

Aggressive behavior can often be displayed physically or verbally. While it can often seem like aggressive behavior is sporadic and sudden, it is usually triggered by emotional or physical discomfort. Understanding the triggers of aggressive behavior after brain injury can help you and your loved one find effective management and prevention techniques.

Common triggers that can contribute to aggressive behavior after brain injury include:

• Overstimulation
• Lack of independence or control
• Perceived insults

Individuals may also struggle with the activities of daily living, such as eating and bathing, and may have difficulty asking for help. Learning how to identify common triggers is the first step toward overcoming aggressive behavior after brain injury.

Demographic And Psychometric Characteristics Of The Study Sample

The three diagnostic groups differed modestly, but significantly, in age, socioeconomic score, and ethnicity distribution, but not in distribution of sex . Accordingly, all relevant analyses factored into these demographic differences. The groups significantly differed in all psychosocial function and satisfaction variables and in all psychometric behavioral variables, as was expected. Finally, the PC and IED groups did not significantly differ in rates of syndromal comorbidity with the exception of lifetime depressive, lifetime substance use, and current and lifetime stress-trauma disorders .

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Statistical Analysis And Data Reduction

For analytic purposes, mTBI subjects were divided into those without history of mTBI , those with a history of mTBI but without LOC , and those with history of mTBI and a brief period of LOC lasting less than 30 minutes . Statistical procedures included chi-square, t test, and analysis of covariance , as appropriate. All reported analyses were adjusted for age, sex, ethnicity, and socioeconomic status. A two-tailed alpha value of 0.05 was used to denote statistical significance for all analyses, except in cases in which a correction for multiple comparisons was more appropriate. Data reduction involved the creation of composite variables for trait aggression and trait impulsivity. Because each of the individual variables related to these dimensions were highly correlated with each other, composite variables were created by z-transforming each individual variable and taking the mean z-score of each of the related variables. Post hoc analyses involved adjustment for comorbid syndromal disorders .

Understanding Aggressive Behavior After Stroke

Its understood that aggressive behavior is common during the acute stages of stroke, especially if the frontal lobe has been affected. This stroke effect may go away on its own.

Available treatments for aggressive behavior after stroke include psychotherapy and medication like the SSRI fluoxetine.

Talk to your doctor and neurologist about the location of the stroke and discuss possible treatments for aggressive behavior. Stay safe, and never lose hope.

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Data Extraction And Assessment Of Methodological Quality

For studies fulfilling inclusion criteria, three authors independently extracted data using a pre-piloted customized data extraction tool based on the standardized tool from the Joanna Briggs Institute System for the Unified Management, Assessment, and Review of Information . The following data were abstracted: basic study identifying information , study methodology , study sample, and findings. All data extracted were checked and verified by the first author . One author was contacted and provided clarification about study characteristics. Data were summarized using tables and narrative synthesis, with results grouped by the primary and secondary outcomes of interest. Study quality was independently assessed by three reviewers using the Joanna Briggs Institute critical appraisal instruments, with all decisions and supporting justifications reviewed and confirmed by author AH .

Exploring Traumatic Brain Injuries And Aggressive Antisocial Behaviors In Young Male Violent Offenders

• 1Lund Clinical Research on Externalizing and Developmental Psychopathology, Child and Adolescent Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
• 2Centre of Ethics, Law and Mental Health, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
• 3Forensic Psychiatric Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
• 4Department of Forensic Psychiatry, National Board of Forensic Medicine, Gothenburg, Sweden
• 5Division of Forensic Psychiatry, Trelleborg, Sweden
• 6Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
• 7Research Department, Regional Forensic Psychiatric Clinic, Växjö, Sweden

Background: Traumatic brain injury is a major cause of disabilities and mortality worldwide, with higher prevalence in offender populations than in the general population. Previous research has strongly advocated increased awareness of TBI in offender populations. The aim of this study was to explore the prevalence and characteristics of TBI, and to investigate associations and interactions between TBI, aggressive antisocial behaviors, general intellectual functioning, and substance use disorders in a well-characterized group of young violent offenders.

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Summary Of Main Findings

The primary aim of this systematic review was to evaluate the evidence for efficacy and harms of pharmacological interventions for aggression following TBI. Ten studies met inclusion criteria: five RCTs and five case series. Multiple studies examined the effects of anti-parkinsonian and anti-epileptic medications, with the remaining studies using neurostimulants, beta-blockers, anti-depressants, and anti-psychotics. Overall, this review concludes based on the evidence from three RCTs conducted in an outpatient community-based setting that there is sufficient evidence to make a recommendation for the use of amantadine in treating aggression and irritability after TBI in the post-PTA period.

Above All Get The Right Treatment

Long-lasting symptoms will not resolve without treatment. If youve experienced emotional problems and other common concussion symptoms for over three months, its time to seek help. Well explain what that looks like in the next section.

Note: While our program primarily serves mTBI patients, we are often able to help severe traumatic brain injury survivors as well. For example, one of our patients feels 95% recovered after a life-threatening fall that left her in a coma for three months. Follow the link for more information on our treatment for severe TBI patients.

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