Traumatic brain injury is the first cause of death and disability in children and young adults in worldwide. During the acute phase of recovery from moderate to severe brain injury, a period of post-traumatic confusion state (PTCS) will arise that is a combination of cognitive and behavioral dysfunction. Seven key symptoms of PTCS are identified and measured by Confusion Assessment Protocol (CAP) Agitation can be part of PTCS in the acute phase or, part of the recovery of consciousness in chronic phase. There are different hypothesis and classifications of acute and chronic post-traumatic aggressive syndromes. While post-traumatic aggression is common, its mechanism, assessment tool, outcome and treatment plans are not well-defined. Understanding the different aspects of post-traumatic aggression; mechanism, differential diagnosis, and treatment are reviewed in this article.
Stuss DT, Binns MA, Carruth FG, Levine B, Brandys CE, Moulton RJ, Snow WG, and Schwartz ML.The acute period of recovery from traumatic brain injury: posttraumatic amnesia or posttraumatic confusional state? J. Neurosurg. 1999;90: 635–43.
Shah SA, Mohamadpour M, Askin G, Nakase-Richardson R, Stokic DS, Sherer M, Yablon SA, Schiff ND. Focal Electroencephalographic Changes Index Post-Traumatic Confusion and Outcome. J Neurotrauma. 2017 Jun 22; 34:1–9.
Sherer M, Nakase-Thompson R, Yablon SA, Gontkovsky ST. Multidimensional assessment of acute confusion after traumatic brain injury. Arch Phys Med Rehabil. 2005 May;86(5):896-04.
Corrigan JD, Mysiw WJ. Agitation following traumatic head injury: equivocal evidence for a discrete stage of cognitive recovery. Archives of Physical Medicine and Rehabilitation 1988;69(7):487–92.
Silver JM, Yudofsky SC, Anderson K: Aggressive disorders. Textbook of Traumatic Brain Injury. Silver JM, MsAllister TA, Yudofsky SC, editors. Washington: American Psychiatric Publishing; 2005, pp 259-78
Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. American Journal of Psychiatry 1986;143:35–9.
Bushman BJ, Anderson CA. Is it time to pull the plug on the hostile versus instrumental aggression dichotomy? J Psychological Review. 2001;108(1):273–9.
Tateno A, Jorge RE, Robinson RG. Clinical correlates of aggressive behavior after traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2003; 15: 155-60,
Rao v, Rosenberg P, Bertrand M, et al: Aggression after traumatic brain injury: prevalence and correlates. J Neuropsychiatry Clin Neurosci. 2009; 21:420-29.
Hagen, C. , Malkmus, D., & Durham, P. Levels of cognitive functioning. In Rehabilitation of the head-injured adult: Comprehensive physical management. CA: Professional Staff Association of Rancho Los Amigos Hospital Inc: 1979. 87-89 p.
Bogner J, Barrett RS, Hammond FM, et al: Predictors of Agitated Behavior During Inpatient Rehabilitation for Traumatic Brain Injury. J Phys Med Rehabil. 2015 Aug;96(8 Suppl):S274-81
Fleminger S, Greenwood RJ, Oliver DL. Pharmacological management for agitation and aggression in people with acquired brain injury (Review). Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003299. Review.
Foster HG, Hillbrand M, Silverstein M. Prog Neuropsychopharmacol Biol Psychiatry. 1993 Nov; 17(6):939-46.
Shah SA, Goldin Y, Conte MM, Goldfine AM, Mohamadpour M, Fidali BC, Cicerone K, Schiff ND. Executive attention deficits after traumatic brain injury reflect impaired recruitment of resources. Neuroimage Clin. 2017 Jan 12;14:233-241.
Baguley IJ, Cooper J, Felmingham K. Aggressive behavior following traumatic brain injury: how common is common? J Head Trauma Rehabil. 2006 Jan-Feb;21(1):45-56.
Nickels J, Schneider W, Dombovy M, Wong T. Clinical use of amantadine in brain injury rehabilitation. J Brain Inj. 1994 Nov-Dec;8(8):709-18.
Mesulam MM. Principles of Behavioral and Cognitive Neurology. 2nd ed. New York: Oxford University Press; 2000.
Hawkins KA, Trobst KK. Frontal lobe dysfunction and aggression: conceptual issues and research findings. Aggression and Violent Behavior. 2000; 2(5): pp. 147–57.
Goyer PF, Andreason PJ, Semple WE, Clayton AH, King AC, Compton-Toth BA, Schulz SC, Cohen RM. Positron-emission tomography and personality disorders. Neuropsychopharmacol. 1994; 10: pp 21–28.
Jorge RE, Robinson RG, Starkstein SE, Arndt SV, Forrester AW, Geisler FH. Secondary mania following traumatic brain injury. Am J Psychiatry. 1993; 150: 916–21.
Engel J Jr, Bandler R, Griffith NC, Caldecott-Hazard S. Neurobiological evidence for epilepsy-induced interictal disturbances. Adv Neurol. 1991;55:97-111.
Kraus M and Maki P. Effect of amantadine hydrochloride on symptoms of frontal lobe dysfunction in brain injury: case studies and review. J Neuropsychiatry Clin Neuorosci. 1997; 9(2): 222–30
Mysiw W,. Sandel M. The agitated brain injured patient, Part 2: pathophysiology and treatment. Arch Phys Med Rehabil. 1997;78: 213–20.
Wroblewski B, Joseph A, Kupfer J, Kalliel K. Effectiveness of valproic acid on destructive and aggressive behaviours in patients with acquired brain injury. Brain Inj. 1997; 11(1):37–47
Emory L, Cole C, Meyer W. Use of depo-provera to control sexual aggression in persons with traumatic brain injury. J Head Trauma Rehabil. 1995;10(3): 47–58.
Corrigan J, Bogner J. Factor structure of the agitated behaviour scale. J Clin and Experimental Neuropsychology. 1994; 16(3): 386–92.
Bagby RM, Parker JDA, Taylor GJ. The 20-Item Toronto-Alexithymia-Scale. 1. Item Selection and Cross-Validation of the Factor Structure. J Psychosom Res. 1994;38(1):23–32.
Halgren E. Emotional neurophysiology of the amygdala within the context of human cognition, in The Amygdala. Neuroboilogical Aspects of Emotion, Memory and Mental Dysfunction. Aggleton JP editor., New York: Wiley-Liss; 1999. pp 191-228
Garryfallos G, Manos N, Adamopoulou A. Psychopathology and personality characteristics of epileptic patients: epilepsy, psychopathology and personality. Acta Psychiatr Scand. 1988; 78:87-95.
kruesi MJ, Hibbs ED, et al. A 2-year prospective followup study of children and adolcents with disruptive behavior disorders: prediction by cerebrospinal fluid 5-hydroxyindolacetic acid, homovallinic acid and autonomic measures. Arch Gen Psychiatry. 1992; 49:429-35.
Levy M, Berson A, Cook T, Bollegala N, Seto E, Tursanski S, Kim J, Sockalingam S, Rajput A, Krishnadev N, Feng C, Bhalerao S. Treatment of agitation following traumatic brain injury: A review of the literature. NeuroRehabilitation. 2005;20(4):279-306. Review. PMID: 16403996
Eichelman B. Neurochemical and psychopharmacologic aspects of aggressive behavior, in Psychopharmacology: The Third Generation of Progress. Meltzer HY, editor. New York:1987, pp 697-04.
McDermott R, Tingley D, Cowden J, Frazzetto G, Johnson DD. Monoamine oxidase A gene (MAOA) predicts behavioral aggression following provocation. Proc Natl Acad Sci USA. 2009 Feb 17;106(7):2118-23
Diaz F. Traumatic brain injury and criminal behavior. Med Law. 1995;14(1-2):131-40. PMID: 7666742
Pappius HM. Brain injury: New insights into neurotransmitter and receptor mechanisms. Neurochem Res. 1991 Sep;16(9):941-9. Review. PMID: 1664496.
Brower MC, Price BH. Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a critical review. J Neurol Neurosurg Psychiatry. 2001 Dec;71(6):720-6.
Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: Prevalence,
neuropsychological functioning and psychiatric disorders. Brain Inj. 2003 Sep;17(9):731-41. PubMed: 12850940
Leach LR, Frank RG, Bouman DE, Farmer J. Family functioning, social support and depression after traumatic brain injury, Brain Inj. 1994 Oct;8(7):599-606.
Hegel MT, Ferguson RJ. Differential reinforcement of other behavior (DRO) to reduce aggressive behavior following traumatic brain injury. Behav Modif. 2000 Jan;24(1):94-101. PMID:10641369
Klonoff PS, Lamb DG, Henderson SW, et al. Outcome assessment after milieu-oriented
rehabilitation: new considerations. Arch Phys Med Rehabil 1998;79:684–690. PubMed: 9630150
Zencius AH, Wesolowski MD, Burke WH, McQuade P. Antecedent control in the treatment of brain-injured clients. Brain Inj. 1989 Apr-Jun;3(2):199-205. PMID: 2730977
Kim E.Agitation, aggression, and disinhibition syndromes after traumatic brain injury.
NeuroRehabilitation. 2002;17(4):297-310. Review.PMID:12547978
Neumann D, Malec JF, Hammond FM. Reductions in Alexithymia and Emotion Dysregulation After Training Emotional Self-Awareness Following Traumatic Brain Injury: A Phase I Trial. J Head Trauma Rehabil. 2017 Jan 5.
Sloane PD, Hoeffer B, Mitchell CM, McKenzie DA, Barrick AL, Rader J, et al. Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: A randomized, controlled trial. Journal of American Geriatrics Society 2004;52:1795–804.
Starkstein SE, Robinson RG. Mechanism of disinhibition after brain lesions. J Nerv Ment Dis 1997;185(2):108–14.
Movahedi B, Azizkhani L, Noori A. Pain Management and Its Related Factors in the Emergency Department of Besat Hospital in Sanadaj, 2016. Internal Medicine And Medical Investigation Journal. 2017 May 22;2(2):33-41.
This work is licensed under a Creative Commons Attribution 4.0 International License.