Traumatic Brain Injury & Aggression

Traumatic brain injury is a common cause of permanent disability in patients who have had a serious automobile accident. The injury can affect mood, speech, mobility, vision and hearing. The part of the brain affected by trauma determines what kind of injury the patient has.

Some people have serious problems with agitation and aggression following a severe traumatic brain injury. The part of the brain affected can be the frontal lobe or the limbic system deeper in the brain. The trauma causes the damaged areas of the brain to make too many or too few neurotransmitters, resulting in changes in behavior.

Some people benefit from psychological drugs that act on the neurotransmitters in the brain. Doctors have to decide on the risks and benefits of taking these medications, and must decide on whether surgery would be better or more efficacious than medications. Medications often used for aggressive behavior include SSRI medications like Zoloft, Prozac and Celexa. SNRI medications like Wellbutrin can help when SSRI medications are ineffective. Atypical antipsychotics are often used for aggression and include medications like Zyprexa, Geodon and Risperdal. All of these medications carry risks and complications so they must be weighed against the benefits of taking these medications. In some cases, mood stabilizers like lithium and Depakote can prevent attacks of mania and aggression that can occur.

Researchers studied the case of a 24 year old male patient who had a severe traumatic brain injury with lesions in the frontal and temporal areas of the brain. He also had a large hematoma outside of the dura and a Glasgow coma scale of 4 out of 15, indicating severe trauma. On the third day after his injury, he required a temporal lobectomy. Over time, he developed severe neurobehavioral difficulties with severe agitation and aggression against his caregivers and family members.

He was placed on maximum doses of antipsychotic drugs and there was no improvement. He was then given antidepressant medication that slightly improved his social abilities. He spent many times in a psychiatric care unit and was institutionalized for psychotherapeutic treatment. With psychotherapy, he got much better and was able to participate in activities with others on the unit. He was also able to walk around alone as long as he was in an enclosed environment.

The researchers noted that aggressive behavior following severe traumatic brain trauma can mean underlying depression and can be partly iatrogenic because of the nature of the hospital and psychiatric ward environments. In this case, the natural thoughts of the attending physicians were to give antipsychotic medications; however, there was only mild sedation and minimal decrease in aggressive behavior. Instead of giving only medications, a multidisciplinary approach is best, which includes social therapy, individual psychotherapy and the consideration to take other medications like antidepressants and mood stabilizers.

Each patient with a traumatic brain injury is different and will have a different cluster of psychiatric symptoms. Doctors need to know what symptoms are present and what medications would work the best to treat these challenging patients.

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