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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 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 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 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.