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Transcript
LARRY E. BANTA MD FAPA
NEUROPSYCHIATRIST
MEDICAL DIRECTOR BEHAVIORAL HEALTH
WEST VALLEY MEDICAL CENTER
OBJECTIVES
 Review and become familiar with the basic
neuroanatomy and physiology of aggression
 Utilizing the understanding of basic neuroanatomy
and physiology develop a basic understanding of
aggression and violence in TBI and Developmental
Disabilities
 With the basic understanding of the neurophysiology
design evaluation and treatment approaches for those
suffering from aggression and violence in these
populations.
Figure 6–1 The hemisected brain from Figure 1–6, used in much of this chapter to indicate planes of section.
Copyright © 2007, 2000, 1995 by Mosby, an affiliate of Elsevier Inc. All rights reserved.
Figure 8–31 A, Afferents to the amygdala.
Copyright © 2007, 2000, 1995 by Mosby, an affiliate of Elsevier Inc. All rights reserved.
The Cycle of Aggression
 Aggression is natural and meant to preserve life and
protect us.
 At a proper level in the proper context it would be
considered appropriate most of the time
 The brain hears sees or feels something that might be
a threat or a danger
 The sensory impulse heads to the thalamus, the brain’s
central processor
The Cycle of Aggression
 The thalamus routes the impulse according to a rapid
assessment of salience to both the frontal cortex and
the temporal lobe but mainly to the amygdala.
 Activation of the amygdala with rage will occur and
move on to the motor cortex to design a motoric
response if uninhibited.
 The orbital frontal cortex assesses the impulse, takes
other input into consideration and places a damper on
the response so that it remains in context or is
completely extinguished.
The Cycle of Aggression
 Brain injury as well as developmental injury to the
brain can cause disconnections
 At the basic level there may be impairment of saliency
determination, might be called paranoia, where
impulses are overinterpreted, calling for major
reaction downstream.
 There may be feedback disconnection so that frontal
input into the level of rage is not transmitted or
transmitted slowly over poorly formed tracts to the
motor cortex and the amygdala.
The Cycle of Aggression
 Disconnection may also be between the limbic
activation and the motor strip. This would cause a
paralysis or a frozen rage.
 Disconnection between the frontal input and the
motor strip could allow complete disinhibition of the
motoric response to the activation.
 Activation causes a dramatic and sudden increase in
several activating neurotransmitters, mostly
norepinephrine, epinephrine, glutamate and likely
many others.
The Cycle of Aggression
 Transmission of impulses is neurochemical as well as
via electric currents mediated by sodium and
potassium channels. Electrical impulses are very rapid.
 Kindling is abnormal electrical transmission without a
seizure but may have other effects
 Seizure activity is organized synchronous electrical
discharge at a level that the brain cannot function
properly causing a variety of manifestations, tonic
clonic, myoclonus, absence spells, automatisms, rage
with usually non-specific targets, deafness, blindness,
apneic episodes and other manifestations.
Temporal Lobe Epilepsy
 This is a rare phenomena, hard to diagnose but can be
a contributor to unexplained rage and aggression
 May occur up to a year or more after an injury
 Episodic amnestic rage with abnormal temporal spikes
on EEG (hard to get without video EEG, 24 hour
monitoring, or special leads)
 Responds fairly well to treatment but tends to have
some interictal deterioration over time.
TRAUMATIC BRAIN INJURY
 Evaluation of a TBI involves a thorough knowledge of
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neurophysiology and neuroanatomy.
What was the nature of the injury?
Ground level fall in elderly or frail?
Concussive/explosive
Blunt trauma
High velocity
Penetrating low or high velocity
Contracoup
TRAUMATIC BRAIN INJURY
 IED injuries and DAI
 Bleeding, epidural, subdural, subarachnoid
 Was there neurosurgical intervention? What was done?
 Where is damage located?
 CT may show deficits, encephalomalacia, residual blood
etc. MRI contrast will show DAI.
 From location of trauma, taking into account contracoup,
GCS, imaging, we can often determine where the problem
is and whether rage or moodswings expected.
DEVELOPMENTAL TRAUMA
 Birthing trauma, forceps, intracranial bleed, shaken
baby, cerebral palsy (often from birthing trauma or
decreased amniotic fluid, abuse of mother etc.)
 Later trauma if occurs prior to age 18 is considered a
developmental disorder but is similar to adult TBI
 Evaluation with imaging, neuropsychological
assessment and neuropsychiatric evaluation.
DEVELOPMENTAL SYNDROMES
 AUTISM SPECTRUM DISORDER rages and aggression
may be associated with meltdowns from being
overwhelmed, changes in routine, changes in
caregivers etc.
 DOWN’S and other trisomies not generally aggressive
but can be.
 FRAGILE X often has autistic features and can be very
aggressive.
 CP can have a variety of manifestations depending on
the extent of damage.
EVALUATION OF RAGE DISORDERS
 Obtain detailed history of development, birth,
milestones, developmental trauma
 Trauma history with as much detail as can be acquired,
type of accident, GCS, length of LOC, residual after
awakening, noticed deficits by caregivers and the
patient
 History of preexisting mental disorder such as Bipolar
Schizophrenia, Depression
 History of seizures, seizure type, frequency, post-ictal
behaviors, aura phenomena
EVALUATION
 MENTAL STATUS EXAM to include specific memory
testing (SLUMS MOCA are easily completed)
 Neurologic Exam looking for soft signs as well as
tremor and irritability (hyperreflexia, hypertonic)
 Review available imaging, neuropsychological testing
and neurosurgical records.
EVALUATION
 Obtain a thorough episode review, start to finish. What
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provokes the rage if anything
What are the symptoms that occur prior to the rage?
Are these stereotypic i.e. the same every time?
Is the rage verbal, physical, directed toward others or nonspecific?
Duration of episode
Post episode behaviors
Associated symptoms, auras, confusion, amnesia for
episode (rage can be amnestic without it being a seizure)
EVALUATION
 Further imaging might be helpful
 Neuropsychological Testing if not done
 General laboratory evaluation to rule out medical
contributors
 Specific genetic testing in the case of developmental
disability that fits particular patterns (such as Fragile
X, Turner’s, etc that can be associated with aggression)
From: Aggression After Traumatic Brain Injury: Prevalence and Correlates
J Neuropsychiatry Clin Neurosci. 2009;21(4):420-429.
Date of download:
1/20/2014
Copyright © American Psychiatric Association.
All rights reserved.
Treatment Approaches
 Any time we design treatment for a disorder we need
to take into consideration the
 BIOPSYCHOSOCIOSPIRITUAL
 Aspects of that disorder, both in causation and in
treatment approaches
TREATMENT APPROACHES
 Neuropsychiatric approaches involve using the
knowledge of the anatomy and physiology along with
specific information about the developmental
syndrome or injury to address specific behaviors and
symptoms.
 There are few medications FDA approved for
neuropsychiatric syndromes.
 Symptoms and behaviors of TBI and DD may mimic
certain mental disorders, and may respond to the same
medication used for those syndromes.
BIOLOGIC TREATMENT
 Episodic disorders often have an electrochemical
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impairment.
Use of AEDs can be very helpful in some aggression.
Levitiracetam has not been shown to positively affect
moods or rage
Carbamazepine Divalproex Oxcarbazepine are helpful
Some respond to addition of Gabapentin.
BIOLOGIC TREATMENT
 If there is a component of anxiety or dysphoria, SSRIs
can benefit but if manifestation is bipolar like, they
may develop worse moodswings.
 If associated with hyperkinetic movement disorder
high potency dopamine blocking can help. (GTS like
syndromes) Haloperidol, Fluphenazine.
 Moodswings irritability, impairment of saliency
determination will respond to atypicals often.
PSYCHOLOGICAL APPROACHES
 Awareness of predisposing factors and cognitive
behavioral approaches to avert activation can be very
helpful.
 Relaxation, mindfulness, guided imagery,
neurofeedback all can be somewhat helpful in
addition to the other approaches.
 Gaining confidence to control the anger and rage,
providing coping skills, dealing with psychological
trauma (which may be more contributory to the rage
than the brain injury in some)
SOCIAL APPROACHES
 Support groups for TBI victims
 Developmental centers for the DD aggressors
 Attachment to other humans (or even pets) can
provide a great deal of help
 Family therapy to assist others in the environment to
be able to understand and assist the patient.
 Engaging them in their positive spiritual resources can
lead to more stability.
SUMMARY
 Aggressive behaviors associated with TBI and
Developmental Disorders can be very overwhelming
and dangerous
 A thorough neuropsychiatric evaluation can lead to
understanding the causative factors and the type of
rage that is presented.
 Biopsychosocial approaches can treat the patient as a
whole, provide relief of symptoms and improve the
quality of life.