Brain Injury And Violence: Understanding The Stroke-Aggression Link

Experiencing a brain injury can be a harrowing experience that can profoundly impact a person's life. Traumatic brain injuries (TBIs) are caused by a sudden blow to the head or a sudden movement violent enough to damage brain tissues. On the other hand, strokes are the result of interrupted or reduced blood supply to the brain, depriving brain tissues of oxygen. While both conditions can damage the brain, there are key differences between them.

One of the negative secondary effects frequently observed in stroke survivors, especially in the acute stage of recovery, is combative or aggressive behaviour. This behaviour can be temporary or, in some cases, long-lasting, and is often a sign of damage to specific areas of the brain, particularly the frontal lobe, which plays a role in reasoning, problem-solving, and controlling basic impulses like anger.

This aggressive behaviour can include physical actions such as hitting, kicking, biting, and throwing objects, as well as verbal outbursts like screaming, refusal of treatment, and muttering unkind or hostile words. It is important to note that these behaviours can be distressing for both the survivor and their caregivers or family members.

While the presence of violent behaviour in stroke patients is concerning, it is typically addressed through treatment and management techniques. Understanding the triggers of aggressive behaviour is a valuable first step in coping with this issue. Additionally, working with a therapist or counsellor can help identify and manage aggressive behaviours effectively.

Anger and aggression

Causes

Research suggests that anger and aggression after a stroke are caused by a combination of factors. One factor is the location of the stroke. When a stroke affects the frontal lobe, lenticulocapsular, or pontine base areas, emotional incontinence (the inability to control emotions) is a likely side effect. This is because the frontal lobe plays a role in reasoning, problem-solving, and controlling basic impulses like anger. When the frontal lobe is damaged, it can affect emotional regulation and lead to aggressive behaviour.

Another factor is neurochemical dysfunction. For example, damage to the brain after a stroke may inhibit the brain's serotonin system, increasing the prevalence of angry or aggressive behaviour. Additionally, negative stimulation from the environment can contribute to combative and aggressive behaviour.

Treatments

There are different treatment options available to address aggressive behaviour after a stroke, including psychotherapy and medications such as selective serotonin reuptake inhibitors (SSRIs). It is important to talk to your doctor and rehab team about the location of the stroke, as well as any symptoms and behavioural changes you are experiencing, such as anger or aggression.

Coping Strategies

Understanding the triggers of aggressive behaviour can be a valuable first step in coping with anger after a stroke. Common triggers include overstimulation, confusion, disruption of routine, and a lack of control over the environment or physical functions.

It is also important to be empathetic towards survivors of stroke, as they are often grieving the loss of their independence and beloved hobbies or activities. This can be hard to accept, especially in the early stages of the recovery process.

Inappropriate behaviour

Other effects of a stroke can also lead to inappropriate behaviour. Pain can make a person irritable, frustration at not being able to do things can make them angry or aggressive, and fatigue can make them avoid social situations or become irritable more easily.

If you or someone close to you is experiencing inappropriate behaviour after a stroke, it's important to seek help. Talking therapy, such as cognitive behavioural therapy (CBT), can help the person learn to think through their actions and understand the effect they can have on others. It can also help family members adjust to the changed behaviour and find a way to be comfortable with it.

Tips for Family and Friends

• Talk about it in the right way: focus on the behaviour and how it makes you feel, rather than making the person feel like they are the problem.
• Don't do it all on your own: get support from a therapist or counsellor to help you come to terms with the changes.
• Be consistent: talk to other friends, family members, and carers to ensure that everyone deals with inappropriate behaviour in the same way.
• Be willing to compromise: just because the person's behaviour has changed doesn't mean it's wrong; it may just be a matter of adjusting to it. Talk honestly about it and find a compromise that you're both comfortable with.

Emotional incontinence

PBA is associated with damage to the anterior cortex-internal capsule/basal ganglia-ventral brainstem circuitry. It is also associated with thalamic or cerebellar lesions. These lesions are similar to those that produce post-stroke depression (PSD), but PBA seems to be more closely related to subcortical (basal ganglia and pontine) lesions. PBA is also associated with alterations in neurotransmitters, particularly serotonin, but also dopamine and glutamine.

PBA is closely associated with post-stroke anger proneness (PSAP) and, like PSAP, is more closely associated with lesion location and consequent neurotransmitter alterations than PSD. PBA is also associated with severe neurological dysfunction, depression, and a history of stroke.

PBA can be treated with selective serotonin reuptake inhibitors (SSRIs), which are better tolerated in stroke patients and more quickly reduce symptoms than tricyclic antidepressants.

Physical behaviours like hitting, kicking, biting, and throwing objects

Experiencing physical aggression from a loved one can be distressing, but it's important to remember that this behaviour is likely a symptom of their brain injury rather than a reaction to you. Understanding the cause of this behaviour can help you better cope with and manage it.

Aggressive behaviour after a stroke is often linked to damage in specific areas of the brain, particularly the frontal lobe. The frontal lobe is responsible for reasoning, problem-solving, and controlling basic impulses like anger. When this area is affected, individuals may struggle with emotional regulation, leading to aggressive or combative behaviour. This can include physical behaviours such as hitting, kicking, biting, and throwing objects.

Additionally, research suggests that neurochemical dysfunction, particularly in the brain's serotonin system, may also contribute to anger and aggression. Serotonin is a neurotransmitter that carries signals between brain nerve cells, and its disruption can increase the prevalence of angry or aggressive behaviour.

To help manage and reduce feelings of anger and aggression, medication such as selective serotonin reuptake inhibitors (SSRIs) can be prescribed. SSRIs are commonly used as antidepressants and work by increasing serotonin levels in the brain. Fluoxetine (Prozac) has been shown to improve "post-stroke anger proneness" and can be an effective treatment option.

While medication can help, it is also important to understand and avoid common triggers for anger and aggressive behaviour. These can include overstimulation from excess lights or sounds, confusion (especially during the acute stage of recovery), disruption of routine, and a lack of control over the environment or physical functions.

Working with a therapist or counsellor can also be beneficial in learning to identify and manage aggressive behaviours. They can help you and your loved one cope with the behavioural changes resulting from the stroke.

Verbal behaviours like screaming, refusal of treatment, and muttering of unkind or hostile words

Experiencing a stroke or brain injury can be a harrowing experience that profoundly impacts a person's life. Behavioural changes are common after a stroke, and these can manifest verbally, physically, or both.

Verbal Behaviours

Verbal behaviours such as screaming, refusal of treatment, and muttering unkind or hostile words can occur after a stroke or brain injury. This type of verbal aggression is quite prevalent, with a reported prevalence of 28.4% in one study. It often takes the form of angry shouts, vicious cursing, and moderate threats of violence.

Several factors may contribute to verbal aggression after a stroke or brain injury:

• Damage to specific brain regions: Lesions in the frontal lobe, temporal lobe, or right hemisphere can impact cognition, emotion regulation, and impulse control, leading to verbal outbursts.
• Communication disorders: Strokes can cause lexical and syntactic disorders, making it difficult for individuals to express themselves effectively, which may contribute to frustration and verbal aggression.
• Emotional factors: Post-stroke depression, anxiety, and irritability are common and can increase the likelihood of verbal aggression.
• Cognitive impairments: Problems with memory, focus, and communication can lead to frustration and difficulty understanding social cues, potentially resulting in verbal outbursts.
• Physical discomfort: Pain, fatigue, and sensory issues can contribute to irritability and verbal aggression.

Strategies for Managing Verbal Behaviours

Managing verbal behaviours can be challenging, but there are strategies that can help:

• Early screening and intervention: Screening for aggression, especially in the first three months after a stroke or brain injury, can help identify those at risk and provide early intervention.
• Addressing underlying issues: Treating depression, providing psychosocial support, and improving social functioning can reduce the frequency and intensity of verbal aggression.
• Developing coping strategies: Teaching individuals to recognise triggers, develop strategies to manage their emotions, and improve self-control can help prevent or minimise verbal outbursts.
• Medication and therapy: In some cases, medication and therapies such as cognitive behavioural therapy or anger management therapy may be beneficial in reducing verbal aggression.
• Support from family and caregivers: Family members and caregivers play a crucial role in helping individuals cope with verbal aggression. This includes creating a peaceful environment, using de-escalation techniques, and providing emotional support.

Frequently asked questions