Welcome to the TBI-HELP Live Chat

  Today's topic is: "Managing Aggression and Anger in Brain Injured Patients"

 Our Guest is: Dr. Lisa Palen Hu, 
Attending Physician TBI Services, Jamaica Hospital Medical Center

[19:00:46] mod: Good Evening Dr. Hu and welcome to our chat room.
[19:02:20] Dr.Hu: Good evening, and thank you very much. I know this is a topic of great concern to a lot of TBI patients and their families.
[19:02:46] Dr.Hu: I will be focusing mostly on medical (pharmacological ) management of aggression tonight
[19:03:29] Dr.Hu: In the upcoming weeks, there will be a chat on behavioral modifications of aggression, although we may touch on that a little tonight
[19:04:16] mod: We have a good question from Rail: What are the common causes of anger and aggressive outburst in TBI patients?
[19:04:28] Dr.Hu: There are many different causes for anger and aggression. These can depend on the stages at which the patient is in. In the early stages, problems such as inadequate arousal function and disorientation may cause agitation.  Later on, as the patient becomes more aware of his/her deficits, frustration may contribute to aggression.  Decreased ability to communicate with others may also produce agitation and aggression.
[19:06:20] Dr.Hu: Certain types of brain injury, especially within the frontal, temporal, and limbic structures of the brain, predisposes patients to disinhibition and aggression.  There are also medical conditions which must be ruled out which can contribute to aggression (treatable medical conditions)
[19:06:56] mod: Is medication ever administered to help alleviate some aggression and agitation?
[19:08:28] mod: It seems that Melanie's question also has to do with medication so we will combine both. Melanie: I would think that drugs can be used to maximize abilities and not be sedative, or have limited unwanted side effects if you find the correct drug and dose. Is that true?
[19:09:10] Dr.Hu: Medications may be used for aggression and agitation, although they are NOT the FIRST LINE of treatment. We try to manage patients with behavioral means first.  However, if behavioral management fails, or if the patient presents with persistent maladaptive behaviors or are at risk for injury to either self or caregivers, we look at medications.  Medications are generally looked at in 2 categories: emergency situations for sedation and in chronic aggression.
[19:11:35] Dr.Hu: In emergency situations, our goal is to use these medications for SHORT periods of time, and only to prevent injur to self/others. Generally, antipsychotics such as HALSOL are used, or benzodiazepines such as ATIVAN
[19:13:16] Dr.Hu: In chronic aggression, there is no particular medication which is FDA approved for aggression; we use medications based on individual responses to drugs which have had some efficacy in different trials
[19:13:18] mod: Carol has a question: How do you tell the difference between agitation caused by a medical condition and one caused by brain injury?
[19:14:12] Dr.Hu: Often, medical causes of agitation and confusion may present as a change from a patient's baseline status.  We are looking for possible seizures, metabolic abnormalities, or infections/new head injuries.  These need to be evaluated and ruled out as new causes for behavioral changes
[19:17:15] mod: I would like to advise our audience that we have a Glossary of medicines for TBI patients. Please feel free to refer to that listing. Thank you.

[19:16:03] mod: Melanie: behavioral means? a sort of reward system?
[19:18:04] Dr.Hu: I will discuss a little bit about behavioral modifications, but this is not my area of expertise. A neuropsychologist will be here in a couple of weeks to discuss this issues.  The first thing to realize is that the behaviors are a result of certain behavior triggers.  We have to identify these triggers (environmental events, people, internal states).  We then need to make environmental changes to decrease the cues for negative behavior.  Many TBI patients benefit from a concrete daily routine.; sustained positive behaviors reduce confusion.
[19:20:24] Dr.Hu: Neuropsychologists work with patients to make choices, provide escapes, undergo relaxation training, develop problem solving techniques.  And it is always important to discuss these and train with the caregivers
[19:20:39] mod: AJM: It must be frightening for the family of patients to see this change? What suggestions do you give them for coping?
[19:21:59] Dr.Hu: Many times, patients will strike out or behave aggressively toward the ones they are closest to or who have the greatest contact with them.  We must make sure we are not doing anything to reinforce these behaviors (e.g., giving them increased attention).
[19:23:03] Dr.Hu: Many TBI centers have support groups for families, and it is important for caregivers to realize that much of this agitation and aggression is a means of communicating a need.  The neuropsychologist will go into this in more depth.
[19:22:46] mod: Once medications are started, how long do they need to be continued?
[19:24:18] Dr.Hu: Medications need to be constantly reevaluated for their efficacy. There is no preset guideline for length of treatment. The  physician must always reassess medications periodically by trying a drug taper (decreased dose) to determine the usefulness of the medication and lowest effective dose
[19:25:17] mod: AJM: Do the patients have any insight into their agitation or must we identify and classify the "triggers"?
[19:27:36] Dr.Hu: It depends on the cause of agitation and aggression. Sometimes these behaviors may be expressions of pain and injury. In the early stages, patients usually do not have an awareness of their behavior due to their confused state.  However, in the later stages, patients may have developed patterns of reinforcement for their aggression (again, attention is a common one) or have lack of alternatives for certain stressful issues.  So although they are aware of "unacceptable" behavior, it has produced positive reward for them in the past, or they do not know other means of expression. This is where behavioral modification comes in.
[19:29:21] mod: When is it appropriate to start medications for aggression/agitation?
[19:30:33] Dr.Hu: When the patient is in risk for injury or when agitation and aggression interferes with social reintegration, treatment and is refractory to behavioral modifications.
[19:30:35] mod: Can this behavior be a pattern of communication if it is not modified?
[19:31:08] Dr.Hu: Absolutely. That is why we need to teach positive skills as an alternative to negative behavior.
[19:33:05] mod: Melanie: Why all the talk of medications. Most injuries do NOT NEED meds to control behavior.
[19:34:05] Dr.Hu: There are times, and many times, when medications are needed, again for emergency situations where quick sedation is needed due to the possibility of injury, as well as in chronic cases of aggression
[19:35:30] Dr.Hu: Medications for chronic aggression run from neuroleptics (seizure medications), beta blockers (a type of cardiac medication) lithium, and certain antidepressants as well as amantadine.
[19:35:41] Dr.Hu: Again, none of these are FDA approved (for this use).
[19:35:34] mod: AJM: Do you need to teach the family or the patients first about positive skills?
[19:36:52] Dr.Hu: Yes. The neuropsychologists and treatment team need to first find out the triggers for aggressive behavior and find alternative ways/escapes for the situations.  These are then oftentimes practiced in controlled settings and then involve the families.
[19:37:20] mod: Melanie: This is a very negative outlook for a TBI survivor, to need all this medication to control behavior! What about the rest of the TBI population that suffers Normal aggression due to frustrations.
[19:38:04] mod: It is starting to seem that a medicated patient is a well behaved patient.
[19:38:59] Dr.Hu: Melanie, I agree. Again, the first line of treatment in behavioral issues with TBI patients is NOT medications. TBI patients are generally more sensitive to the side effects of medications, and there are a number of them which may hamper brain recovery. The medications which are used were found to help through trials, : but oftentimes, these are secondary effects of the medications and not what they were originally devised for.
[19:40:09] Dr.Hu: WE only advocate medication when there are great risks for injury, when other conservative methods fail,. or when maladaptive behavior persists
[19:39:56] mod: June is a survivor. She was in a car accident 4 years ago and sustained a brain injury.
[19:41:08] Dr.Hu: Hello, June. Have you had experience with frusta ration following your car accident?
[19:42:54] mod: JUNE: yes my behavior
[19:44:08] Dr.Hu: Would you like to tell us what kind of problems you are seeing now that you have left the hospital ?
[19:45:03] mod: JUNE: i was in the tbi unit
[19:46:55] Dr.Hu: How are you doing now? Do you have a problem with stress or relating to other people?
[19:48:25] mod: Rail: Dr. Hu - after the chat could you pull together an updated listing of medications that are currently useful in TBI aggression control. etc? We could post it to the site to help others.
[19:50:18] Dr.Hu: Absolutely. I can put together a list of medications which have shown in various trials to be effective in controlling agressive behavior. Again, remember that these are not FDA approved indications, and each indivicual may have a differening response to the medications. There are also various side effects, which I will try to list, so they need to be used always under medical supervision
[19:51:09] mod: Melanie: I haven't heard any suggestions on how family can handle this aggression other than joining with the neuropsychologist for sessions with the patient. Those of us at home need management hints.
[19:53:48] Dr.Hu: Melanie, if you don't mind, I will defer most of this until the neuropsychologist comes in. Many of the comprehensive programs work with therapists and families, but social support is absolutely critical. Usually, the neuropsychologists are there to help determine the stimuli for behavior. The families/caregivers work to create an environment which is reinforcing to ensure success, and which is encouraging and supportive.  Many times, families can try to redirect the attention of the patient.  It is also important to avoid aversive treatment techniques when possible.  These techniques do not teach patients how they should behave, but provide a poor model for future behavior
[19:55:01] mod: AJM: is asking: Can any of the herbal meds out there help?
[19:56:20] Dr.Hu: I don't know too much about herbal medications, but there are certain medications which act like a group of antidepressants called serotonin-reuptake inhibitors which have been shown to be effective in aggressive TBI patients. However, I have not seen any literature on the subject
[19:56:39] mod: Please always remember to check with your own Dr. before any medications are given.
[19:57:58] mod: Melanie: How about acknowledging the frustration and anger as real. That would be a big help for the person to know there are real issues.
[19:58:12] Dr.Hu: Melanie, you are absolutely right. It is important for everyone to realize that such behavior often does not exist in and of itself, but is a means of communication and can over time become a learned behavior.  We must find out the precipitating factors and help the patient find alternative ways of communicating their needs and frustrations
[19:59:10] mod: AJM: Do many of these patients that have anger issues also have depression?
[20:01:13] Dr.Hu: Yes. Aggression/agitation is just one of the behaviors which can result following TBI. Anxiety, depression, fatigue, attention problems, irritability, as well as various cognitive deficits may also present, to name a few. There will be a web chat in the near future with a psychiatrist, who will discuss these various issues.
[20:01:17] mod: Well, we have come to the end of our chat session and I want to thank Dr Hu for an interesting evening and also to thank all of you for your participation. See you next week, Good Night.
[20:02:00] Dr.Hu: Thank you all for your time and questions. I hope this was of some help.