Vani Rao and Sandeep Vaishnavi on what we need to know about people who’ve dealt and are dealing with traumatic brain injury.
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As Lee walked through a store parking lot headed for his car, another car backed out from a parking space and knocked him down. Lee’s head hit the pavement and he lost consciousness. An ambulance took him to the nearest emergency department, where a brain scan showed bleeding in the space between his skull and brain. Brain surgeons immediately removed the blood clot. The operation was successful—Lee was healthy and strong at 23—but he had a prolonged hospital stay and required extensive rehabilitation. While in the hospital, Lee developed seizures and had episodes of agitation immediately after he was admitted, but both conditions resolved over time.
After Lee returned home, he had emotional outbursts over trivial matters. For example, a minor disagreement at the dinner table with his family escalated into a shouting match, and Lee stormed off, punching holes in walls. At one point, Lee became so enraged over an empty cereal box that he wrenched the cupboard door off its hinges. Lee’s wife reported, “The children are terrified of him now.” Because of these aggressive episodes, it has been hard for Lee to get into a day program whose goal is to help him transition back to work.
Aggression is hostile, harmful, or destructive behavior that can be physical or verbal and can range from irritability to physical assault. Aggression is common after traumatic brain injury (TBI) with rates ranging from 10-30%. Aggression can manifest as cursing, threatening, hitting, pushing, yelling, or breaking or throwing things. It is more common after repeated injuries and severe injuries. Risk factors for developing aggression after TBI include having a TBI at a young age, alcohol or substance abuse problems before or after the TBI, injury to specific parts of the brain such as the frontal and temporal lobes, and the onset of mood problems after the TBI. Even though TBI is more common in males than in females, most research studies have not shown significant gender differences in rates of aggression.
Aggressive behaviors after TBI tend to be impulsive, without planning or forethought. In Lee’s case, in our opening story, trivial disagreements made him agitated and aggressive. Aggression after TBI is thus not criminal violence, in which criminals plot and plan, execute a crime, then make their planned escape. Just as aggression after TBI typically builds up suddenly, it also dies down abruptly. Indeed, people with TBI usually regret their outburst.
Aggression soon after the TBI, in the context of confusion and disorientation, is usually due to delirium. This aggressive behavior is the direct result of the trauma to the brain and/or subsequent alterations in body physiology or of medications administered after the TBI.
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Aggression can occur soon after the TBI or months later. Aggression soon after the TBI, in the context of confusion and disorientation, is usually due to delirium. This aggressive behavior is the direct result of the trauma to the brain and/or subsequent alterations in body physiology or of medications administered after the TBI. In the chronic period (3 months or more after the TBI), aggression can be associated with clinical depression, post-traumatic stress disorder (PTSD), alcohol or illicit drug use and/or chronic pain. Other social factors, such as trouble adjusting to a new level of functioning or becoming dependent on family, can also be associated with irritability and agitation. Finally, TBI-related factors, such as injury to specific brain regions (frontal lobes, temporal lobes, amygdala, hypothalamus) and imbalance of brain chemicals (increased norepinephrine or dopamine, or decreased serotonin or GABA), can be associated with aggression.
There might also be a genetic predisposition to aggression after TBI, expressed by a gene for an enzyme called monoamine oxidase type A (MAO-A). This enzyme is important in breaking down dopamine, norepinephrine, and serotonin. People who have a genetic predilection for low levels of MAO-A may be more likely to be aggressive when provoked, presumably because they cannot break down some of these neurotransmitters (particularly norepinephrine and dopamine) effectively.
With regard to treatment, aggression in the acute stage (which often stems from delirium) requires careful medical evaluation. The treating doctor will make a determination on whether or not to use medication. The treatment of chronic aggression involves a combination of environmental modifications and talk and behavioral therapy. The latter, involves assessing the antecedents to the behavior, the behavior itself, and the consequences of the behavior, also known as the ABCs of assessing behavior problems. Therapists who specialize in working with people who have brain injury are most qualified to perform these behavioral and environmental interventions, but caregivers should be aware of these principles as well. The professional may create a plan—in a rehabilitation setting, for example—and it is up to caregivers to implement the plan when the person with TBI returns home.
There are medications for chronic aggression, and doctors often prescribe them in combination with the behavioral and environmental techniques discussed above. Medications include antidepressants, beta blockers, mood stabilizers, anti-psychotics or sometimes even stimulants. After a comprehensive evaluation, the doctor will be able to choose the most appropriate medicine.
In summary, aggression after TBI can be disconcerting to all involved. Family and caregivers must recognize that aggression after TBI is often a consequence of factors beyond a person’s control. As we have noted, there are multiple potential causes of the aggression, ranging from direct effects of the TBI, other medical issues, medications, and social factors. A number of pharmacological and non-pharmacological options are available to help control this behavior and return more quickly to a higher functioning level.
Tips for Coping with Aggression after TBI
If you know someone who is experiencing aggression after TBI:
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.
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Call 911 if you are concerned about safety. Safety comes first, both the safety of the person experiencing aggression and of those around him.
Respond, but don’t 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 (for example, too much noise, bright lights, cluttered space), people involved in the person’s care (loud conversations, too many directions given at once), or something the person with aggression is doing or not doing (using alcohol or illicit drugs, sleeping poorly, taking certain medications).
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.
Think outside the box. If the coping strategies you have devised just aren’t working, keep searching for other methods. Seek guidance and help from doctors, therapists, or support groups.
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Excerpted from The Traumatized Brain: A Family Guide to Understanding Mood, Memory, and Behavior after Brain Injury, Copyright 2015 by Johns Hopkins University Press.
Vani Rao, MD, director of the Brain Injury Program at Johns Hopkins Medicine, and Sandeep Vaishnavi, MD, PhD, director of the Neuropsychiatric Clinic at Carolina Partners, are the co-authors of The Traumatized Brain: A Family Guide to Understanding Mood, Memory, and Behavior after Brain Injury.
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