Evolution of Irritability, Anger, and Aggression after Traumatic Brain Injury: Identifying and Predicting Subgroups

A symptom-level perspective on irritability, PTSD, and depression in children and adults

BACKGROUND

Although irritability is a prominent clinical manifestation among traumatized populations, its relationships with other psychopathologies are rarely studied. Adopting a symptom-level perspective, this study aimed to explore how symptoms of irritability, posttraumatic stress disorder (PTSD), and depression are associated.

METHOD

The Brief Irritability Test, the PTSD Checklist for DSM-5, and the Patient Health Questionnaire-9 were used to measure irritability, PTSD, and depression, respectively, in a large sample of trauma-exposed children and adolescents (n = 5454), trauma-exposed adults (n = 4718), and children and adolescents with probable PTSD (n = 556). Exploratory graph analysis (EGA) and network analysis were conducted to examine potential communities and significant relations.

RESULTS

Although irritability, PTSD, and depression were highly correlated at the disorder level, EGA results indicated that, at the symptom level, they formed highly stable and dense communities, respectively. Relations across disorders mainly emerged at symptoms related to negative cognition, dysphoria, and suicidal thoughts. Especially, strong transdiagnostic relations across all samples were "negative beliefs" and "suicidal thoughts", "numbing" and "suicidal thoughts", "startle" and "moving slowly or restless", "bothering" and "moving slowly or restless". Furthermore, irritability symptoms seem more central than PTSD and depression symptoms, with "snap" being the most central node across all networks, especially in the child and adolescent sample.

CONCLUSION

Irritability, PTSD, and depression are relatively independent constructs when analyzed at the symptom level. Irritability symptoms emerged as core symptoms in trauma-exposed populations. Our findings highlight the importance of independent assessment of irritability in the diagnosis and treatment of PTSD.

Menopause and Traumatic Brain Injury: A NIDILRR Collaborative Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine the experience of menopause symptoms in women with traumatic brain injury (TBI).

DESIGN

Cross-sectional descriptive study.

SETTING

Five sites of the TBI Model Systems (TBIMS) program.

PARTICIPANTS

Participants were 210 women, aged 40-60 years, who were not taking systemic hormones and did not have both ovaries removed: 61 participants were enrolled in the TBIMS, who were at least 2 years post-TBI and living in the community. One hundred forty-nine participants without TBI were recruited from a research registry and the metropolitan Detroit community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A checklist comprised of 21 menopause symptoms assessing 4 symptom clusters (vasomotor, somatic, psychological, and cognitive).

RESULTS

TBI and non-TBI groups did not significantly differ and showed small effect sizes on vasomotor symptoms. On the remaining symptom clusters, women with TBI showed greater presence and severity of symptoms than women without TBI, as well as fewer differences between premenopausal and postmenopausal women on those symptoms. A profile indicating an additive or potentiating effect of TBI on menopause symptoms was not observed.

CONCLUSIONS

Findings support a conceptual model of menopause and TBI indicating that symptoms most closely associated with estrogen decline are similar for women with and without TBI, whereas symptoms that overlap with common TBI sequelae are generally more frequent and severe among these women. Likely because of lower baseline of symptoms premenopause, postmenopausal women without TBI reported more numerous and severe symptoms relative to their premenopausal counterparts without TBI. Overall, it may be that women without TBI experience menopause as more of a "change" of life, whereas women with TBI chronically face significantly more of these symptoms than women without TBI.

Alexithymia Prevalence, Characterization, and Associations With Emotional Functioning and Life Satisfaction: A Traumatic Brain Injury Model System Study

OBJECTIVES

Alexithymia an emotional processing deficit that interferes with a person's ability to recognize, express, and differentiate emotional states. Study objectives were to (1) determine rates of elevated alexithymia among people with moderate-to-severe traumatic brain injury (TBI) 1-year post-injury, (2) identify demographic and injury-related variables associated with high versus low-average levels of alexithymia, and (3) examine associations among alexithymia with other aspects of emotional functioning and life satisfaction.

SETTING

Data were collected during follow-up interviews across four TBI Model System (TBIMS) centers.

PARTICIPANTS

The sample consisted of 196 participants with moderate-to-severe TBI enrolled in the TBIMS. They were predominately male (77%), White (69%), and had no history of pre-injury mental health treatment (66.3%).

DESIGN

Cross-sectional survey data were obtained at study enrollment and 1-year post-injury.

MAIN MEASURES

Toronto Alexithymia Scale-20 (TAS-20) as well as measures of anger, aggression, hostility, emotional dysregulation, post-traumatic stress, anxiety, depression, resilience and life satisfaction. Sociodemographic information, behavioral health history and injury-related variables were also included.

RESULTS

High levels of alexithymia (TAS-20 score > 1.5 standard deviation above the normative mean) were observed for 14.3%. Compared to individuals with low/average levels of alexithymia, the high alexithymia group tended to have lower levels of education. At 1-year follow-up, high TAS-20 scores were strongly associated with emotional dysregulation and post-traumatic stress; moderately associated with anger, hostility, depression, anxiety, lower resilience and lower satisfaction with life; and weakly associated with aggression.

CONCLUSION

These findings provide further evidence that alexithymia is associated with poor emotional functioning and life satisfaction after TBI. Longitudinal studies are needed to determine if alexithymia is a risk factor that precipitates and predicts worse emotional outcomes in the TBI population. This line of work is important for informing treatment targets that could prevent or reduce of psychological distress after TBI.

Exercise as a behavioral approach to improve mood in persons with traumatic brain injury

Mood disturbance is a common, long-term, negative consequence of traumatic brain injury (TBI) that is insufficiently addressed by most traditional treatment modalities. A large body of evidence supports the efficacy of exercise training (ET) to broadly improve mood, as measured most often by the Profile of Mood States (POMS). However, this behavioral approach is not used nearly enough in the TBI population, and when it is, mood is rarely measured. This scoping review will evaluate the use of POMS as a mood measure in TBI research and to establish a rationale for using ET as a behavioral approach to broadly improve mood in persons with TBI.

Insights into epileptogenesis from post-traumatic epilepsy

Post-traumatic epilepsy (PTE) accounts for 5% of all epilepsies. The incidence of PTE after traumatic brain injury (TBI) depends on the severity of injury, approaching one in three in groups with the most severe injuries. The repeated seizures that characterize PTE impair neurological recovery and increase the risk of poor outcomes after TBI. Given this high risk of recurrent seizures and the relatively short latency period for their development after injury, PTE serves as a model disease to understand human epileptogenesis and trial novel anti-epileptogenic therapies. Epileptogenesis is the process whereby previously normal brain tissue becomes prone to recurrent abnormal electrical activity, ultimately resulting in seizures. In this Review, we describe the clinical course of PTE and highlight promising research into epileptogenesis and treatment using animal models of PTE. Clinical, imaging, EEG and fluid biomarkers are being developed to aid the identification of patients at high risk of PTE who might benefit from anti-epileptogenic therapies. Studies in preclinical models of PTE have identified tractable pathways and novel therapeutic strategies that can potentially prevent epilepsy, which remain to be validated in humans. In addition to improving outcomes after TBI, advances in PTE research are likely to provide therapeutic insights that are relevant to all epilepsies.

Distinguishing Characteristics of Admissions to Various Types of Posthospital Brain Injury Rehabilitation Programs

OBJECTIVE

Describe and compare the demographic characteristics and disability profiles of individuals admitted to 6 types of posthospital brain injury rehabilitation (PHBIR) programs.

SETTING

Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and Supported Living programs serving individuals with acquired brain injury (ABI).

PARTICIPANTS

Two thousand twenty-eight individuals with traumatic brain injury (TBI), stroke, or other ABI.

MAIN MEASURES

Sex, age, time since injury, and Mayo-Portland Adaptability Inventory, 4th edition (MPAI-4).

DESIGN

Retrospective analyses of demographic variables and MPAI-4 Total, Index, and subscale Rasch-derived T-scores on admission comparing diagnostic categories and program types within diagnostic categories.

RESULTS

Participants with TBI were predominantly male, and those with stroke were generally older. Admissions to more intensive and supervised programs (residential neurobehavioral and residential neurorehabilitation) generally showed greater disability than admissions to home and community programs who were more disabled than participants in day treatment and outpatient programs. Residential neurobehavioral and supported living program participants generally were male and had TBI. Home and community admissions tended to be more delayed than residential neurorehabilitation admissions. The majority of those with other ABI were admitted to outpatient rather than more intensive programs. Additional analyses demonstrated significant differences in MPAI-4 profiles among the various program types.

CONCLUSIONS

Admissions with TBI, stroke, and other ABI to PHBIR differ in demographic factors and disability profiles. When examined within each diagnostic category, demographic features and disability profiles also distinguish among admissions to the various program types. Results provide insights about decision-making in referral patterns to various types of PHBIR programs, although other factors not available for analysis (eg, participant/family preference, program, and funding availability) likely also contribute to admission patterns.

Traumatic Brain Injury and Related Antisocial Behavioral Outcomes: A Systematic Review

Background and Objectives: Higher level of aggression and antisocial behavior have been found in the period following head trauma. These changes are attributable to specific brain alterations that generally involved frontal lobe, insula and limbic system. A descriptive review was conducted on the specificity of aggressive behavior in relation to traumatic brain injury by evaluating numerous variables, focusing on age at the time of trauma and neuroimaging studies. Materials and Methods: We searched on PubMed and the Web of Science databases to screen references of included studies and review articles for additional citations. From an initial 738 publications, only 27 met the search criteria of describing the relationship between aggression, brain alterations and traumatic brain injury. Results: These findings showed that traumatic brain injury (TBI) is related to changes in behavior, personality and mood. Conclusions: The development of aggressive and criminal behavior is associated with multiple factors, including the etiology of injury, environmental, psychosocial and personality factors and age at the time of trauma.

Putting the pieces together to understand anger in combat veterans and service members: Psychological and physical contributors

Dysregulated anger can result in devastating health and interpersonal consequences for individuals, families, and communities. Compared to civilians, combat veterans and service members (C-V/SM) report higher levels of anger and often have risk factors for anger including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), pain, alcohol use, and impaired sleep. The current study examined the relative contributions of established variables associated with anger (e.g., combat exposure, current PTSD symptoms, history of TBI, pain interference, and hazardous alcohol use) in 1263 C-V/SM. Sleep impairments, represented by poor sleep quality and obstructive sleep apnea (OSA) risk, were also evaluated as potential mediators of the relationships between established risk factors and anger, and therefore potential modifiable treatment targets. Multiple regression model results revealed that PTSD symptoms (β = 0.517, p < .001), OSA risk (β = 0.057, p = .016), pain interference (β = 0.214, p < .001), and hazardous alcohol use (β = 0.054, p = .009) were significantly associated with anger. Results of the mediation models revealed that OSA risk accounted for the association between PTSD and anger, in addition to the association between pain interference and anger. The current study extends previous literature by simultaneously examining factors associated with anger using a multivariable model in a large sample of C-V/SM. Additionally, treating OSA may be a novel way to reduce anger in C-V/SM who have PTSD and/or pain interference.

Neurobiological Mechanisms Of Depression Following Traumatic Brain Injury

OBJECTIVE

Depression is among the most pervasive and debilitating neuropsychiatric sequelae experienced by patients following a traumatic brain injury (TBI). While the individual mechanisms underlying depression and TBI have been widely studied, the neurobiological bases of depression after TBI remain largely unknown. This article highlights the potential mechanisms of action implicated in depression after TBI.

RESULTS

We review putative mechanisms of action including neuroinflammation, neuroendocrine dysregulation, metabolic abnormalities, and neurotransmitter and circuitry dysfunction. We also identify the current limitations in the field and propose directions for future research.

CONCLUSION

An improved understanding of the underlying mechanisms will aid the development of precision-guided and personalized treatments for patients suffering from depression after TBI.

Comparability of (Post-Concussion) Symptoms across Time in Individuals after Traumatic Brain Injury: Results from the CENTER-TBI Study

Post-concussion symptoms often occur after TBI, persist and cause disabilities. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) is widely used in this population, but little is known about the comparability of the symptoms over time, i.e., longitudinal measurement invariance (MI). The objectives of this study were to analyze the longitudinal MI of RPQ symptoms from three to twelve months after TBI and to find factors related to RPQ symptoms. The study involved 1023 individuals after TBI who took part in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study and completed the RPQ at three, six and twelve months post-injury. Longitudinal confirmatory factor analysis showed that the three-factor structure (somatic, emotional and cognitive) remains stable within one year after TBI. Linear mixed models revealed that sex, injury cause and prior psychiatric problems were related to the RPQ three-factor structure as well as to the RPQ total score. The study strengthens evidence for the RPQ’s factorial structure stability within one year after TBI and identifies sex, injury cause and prior psychiatric problems as important factors that may help clinicians to prevent future complications of symptomatology after TBI.