Self-reported aggressive behavior in patients with stroke

Post-stroke aggressive behavior in patients wıth first-ever ischemic stroke: underlying clinical and imaging factors

BACKGROUND

Aggression is defined as a complex behavior consisting of a combination of sensory, emotional, cognitive and motor elements. We aimed to examine the relationships between post-stroke aggressive behavior (PSAB) and neuropsychological and neuroimaging findings.

METHODS

380 patients in the stroke unit were classified as aggressive or non-aggressive based on symptoms elicited by the Neuropsychiatric Inventory (NPI) and aggression screening questionnaire.

RESULTS

Aggressive behavior was detected in 42 (11.1%) of 380 patients who had a first ischemic stroke. Patients with PSAB were older than those without (338 patients) (66.98 + 13.68 vs. 62.61 + 13.06, P = 0.043). Hamilton depression and anxiety scales showed significantly higher rates of depression and anxiety in the PSAB group compared to the non-PSAB group (47.6% vs. 16.3% and 57.1% vs. 15.4%, respectively; P = 0.001). Lesion mapping analysis showed that lesions in patients with PSAB mostly included the lower parietal lobe and lateral frontal gyrus. Multiple regression analysis showed that gender (OR, 2.81; CI%, 1.24-6.39), lateral prefrontal infarction (OR, 6.43; CI%, 1.51-27.44), parietal infarction (OR, 2.98; CI%, 1.15-7.76), occipital infarction (OR, 2.84; CI%, 1.00-8.06), multiple infarcts (OR, 5.62; CI%, 2.27-13.93), anxiety (OR, 2.06; CI%, 0.89-4.81) and verbal memory deficit (OR, 4.21; CI%, 1.37-12.93) were significant independent predictors of PSAB.

CONCLUSION

The presence of PSAB may be related to neuropsychiatric symptoms such as high anxiety and verbal memory impairment, and neuroanatomical location of the lesions.

A narrative review of psychiatric features of traumatic encephalopathy syndrome as conceptualized in the 20th century

Introduction

Some ultra-high exposure boxers from the 20th century suffered from neurological problems characterized by slurred speech, personality changes (e.g., childishness or aggressiveness), and frank gait and coordination problems, with some noted to have progressive Parkinsonian-like signs. Varying degrees of cognitive impairment were also described, with some experiencing moderate to severe dementia. The onset of the neurological problems often began while they were young men and still actively fighting. More recently, traumatic encephalopathy syndrome (TES) has been proposed to be present in athletes who have a history of contact (e.g., soccer) and collision sport participation (e.g., American-style football). The characterization of TES has incorporated a much broader description than the neurological problems described in boxers from the 20th century. Some have considered TES to include depression, suicidality, anxiety, and substance abuse.

Purpose

We carefully re-examined the published clinical literature of boxing cases from the 20th century to determine whether there is evidence to support conceptualizing psychiatric problems as being diagnostic clinical features of TES.

Methods

We reviewed clinical descriptions from 155 current and former boxers described in 21 articles published between 1928 and 1999.

Results

More than one third of cases (34.8%) had a psychiatric, neuropsychiatric, or neurobehavioral problem described in their case histories. However, only 6.5% of the cases were described as primarily psychiatric or neuropsychiatric in nature. The percentages documented as having specific psychiatric problems were as follows: depression = 11.0%, suicidality = 0.6%, anxiety = 3.9%, anger control problems = 20.0%, paranoia/suspiciousness = 11.6%, and personality change = 25.2%.

Discussion

We conclude that depression, suicidality (i.e., suicidal ideation, intent, or planning), and anxiety were not considered to be clinical features of TES during the 20th century. The present review supports the decision of the consensus group to remove mood and anxiety disorders, and suicidality, from the new 2021 consensus core diagnostic criteria for TES. More research is needed to determine if anger dyscontrol is a core feature of TES with a clear clinicopathological association. The present findings, combined with a recently published large clinicopathological association study, suggest that mood and anxiety disorders are not characteristic of TES and they are not associated with chronic traumatic encephalopathy neuropathologic change.

Risk for Misdiagnosing Chronic Traumatic Encephalopathy in Men With Anger Control Problems

Background: There are no validated or agreed upon criteria for diagnosing chronic traumatic encephalopathy (CTE) in a living person. In recent years, it has been proposed that anger dyscontrol represents a behavioral clinical phenotype of CTE. This is the first study to examine the specificity of the diagnostic research criteria for traumatic encephalopathy syndrome (TES, the clinical condition proposed to be CTE) in men from the US general population who have anger dyscontrol problems. It was hypothesized that a substantial percentage of these men would meet the research criteria for TES. Methods: Data from 4,139 men who participated in the National Comorbidity Survey Replication, an in-person survey that examined the prevalence and correlates of mental disorders in the United States, were included in this study. Men who were diagnosed with intermittent explosive disorder in the past year were the clinical sample of interest (n = 206; 5.0% of all men in the database), and the remaining men were used as a comparison sample. They were classified as meeting the research criteria for TES if they presented with the purported supportive clinical features of CTE (e.g., impulsivity/substance abuse, anxiety, apathy, suicidality, headache). Results: In this sample of men from the general population with intermittent explosive disorder, 27.3% met a conservative definition of the proposed research criteria for CTE (i.e., traumatic encephalopathy syndrome). If one assumes the delayed-onset criterion is present, meaning that the men in the sample are compared to former athletes or military veterans presenting with mental health problems years after retirement, then 65.0% of this sample would meet the research criteria for TES. Conclusions: These results have important implications. Using conservative criteria, at least one in four men from the general population, who have serious anger control problems, will meet the symptom criteria for TES. If one considers former athletes and military veterans with anger control problems who present many years after retirement and who experienced a documented decline in their mental health, nearly two-thirds will meet these research criteria. More research is needed to examine risks for misdiagnosing TES and to determine whether anger dyscontrol is a clinical phenotype of CTE.

Neurobehavioral disability in stroke patients during subacute inpatient rehabilitation: prevalence and biopsychosocial associations

BACKGROUND AND OBJECTIVES

There are scarce data on post-stroke neurobehavioral disability (NBD). The aim of this study was to identify the prevalence of NBD in a subacute inpatient stroke population and examine potential associations with demographic, stroke-related, functional and psychosocial variables.

METHODS

82 survivors of stroke were consecutively recruited during their inpatient rehabilitation admission. Nursing staff rated NBD in patients using the St Andrews -Swansea Neurobehavioral Outcome Scale (SASNOS). Measures of patient functional independence (FIM), cognition (MoCA), and mood symptoms (HADS) were collected in addition to nursing reports of whether observed NBD negatively impacted on the patient or those around them.

RESULTS

NBD relating to interpersonal relationships (44.4% of participants) and cognition (52.4%) were highly prevalent within the sample while NBD relating to inhibition (1.2%), aggression (3.6%), and communication (2.5%) were relatively rare. Presence of NBD was significantly associated with reduced functional independence (rs=0.39, p < 0.01) and associated with trends in cognitive impairment (rs=0.29, p = 0.03), increased anxiety (rs=-0.43, p = 0.02) and depressive symptoms (rs=-0.43, p = 0.02). Presence of NBD was significantly correlated with negative impact to the patient and those around them across all SASNOS domains (rs range 0.42 - 0.45, all p ≤ 0.01).

CONCLUSIONS

NBD is common within a subacute stroke inpatient population, particularly interpersonal and cognitive difficulties and preliminary analyses indicate associations with reduced functional ability, cognition and mood. There is a need to provide education and support to clinicians to facilitate routine assessment and management of NBD following stroke.

Anger and stroke: a potential association that deserves serious consideration

OBJECTIVE

To assess the relationship between states of anger and stroke.

METHODS

Systematic review of the literature.

RESULTS

In total, 21 papers were selected for the systematic review of data published on the subject of anger and stroke. A state of anger may be a risk factor for stroke, as well as a consequence of brain lesions affecting specific areas that are caused by a stroke. Scales to assess anger varied among authors. There was no consensus regarding the area of brain lesions that might lead to a state of anger. Although some authors agreed that lesions on the right side led to angrier behaviour, others found that lesions on the left side were more relevant to anger. Likewise, there was no consensus regarding the prevalence of anger pre or post-stroke. Some authors did not even find that these two conditions were related.

CONCLUSION

Although most authors have accepted that there is a relationship between anger and stroke, studies with uniform methodology need to be conducted if this association is to be properly evaluated and understood.

Poststroke agitation and aggression and social quality of life: a case control study

BACKGROUND AND OBJECTIVE

Aggression and agitation are common after a stroke. The association between agitation/aggression following stroke and Health-Related Quality of Life (HRQoL) in stroke survivors is unknown. This study aimed to examine the association between agitation/aggression and HRQoL in Chinese stroke survivors.

METHODS

Three hundred and twenty-four stroke patients entered this cross-sectional study. Agitation/aggression was assessed using the Chinese version of Neuropsychiatric Inventory (CNPI). HRQoL was measured with the Stroke Specific Quality of Life (SSQoL).

RESULTS

Three months after the index stroke, agitation/aggression was found in 60 (18.5%) patients. In the agitation/aggression group, 44 patients (73.3%) showed passive agitation/aggression, whereas 16 (26.7%) displayed passive and active agitation/aggression. No patients showed only active agitation/aggression. Patients with agitation/aggression were more likely to have history of diabetes and greater severity of depression, as well as lower SSQoL total score and Personality Changes and Social Role scores. Controlling for diabetes and depression severity did not alter the above results. The Energy and Thinking scores of the SSQoL were significantly lower in the passive/active agitation/aggression group relative to the passive agitation/aggression group (adjusted for CNPI aggression/agitation score).

CONCLUSION

In this study sample, agitation/aggression was preponderantly of the passive type and was associated with poorer HRQoL independently from depression or medical conditions. Patients with both passive and active agitation/aggression had lower Quality of Life (QoL) than patients with only passive agitation/aggression. The causality of the association between low QoL and agitation/aggression needs to be explored in future studies.

Síndromes neuropsiquiátricas associadas a acidentes vasculares encefálicos: revisão de literatura

Objetivo Revisar as principais síndromes neuropsiquiátricas associadas ao acidente vascular encefálico (AVE), suas características clínicas, impacto sobre a recuperação dos pacientes, tratamento, suas possíveis relações com a fisiopatologia dos AVE e, quando possível, contextualizá-las à realidade brasileira. Métodos Foram realizadas buscas nas bases de dados PubMed/MedLine e SciELO/Lilacs com os termos “stroke” e “cerebrovascular disease” em combinações com “neuropsychiatry”, “neuropsychiatric disorders”, “psychiatry”, “psychiatric disorders”, “depression”, “anxiety” e “dementia”, com ênfase nos últimos dez anos. Resultados Foram revisadas as síndromes neuropsiquiátricas pós-AVE, incluindo depressão, ansiedade, transtorno da expressão emocional involuntária, labilidade emocional, irritabilidade, raiva, reação catastrófica, apatia, demência, mania e psicose, de acordo com os objetivos propostos. Conclusão É notória a escassez de informações sobre o manejo terapêutico das complicações neuropsiquiátricas secundárias aos AVE, especialmente diante do impacto em saúde pública representado pelas doenças cerebrovasculares. Com a evolução da abordagem precoce a esses pacientes e o consequente aumento de sua sobrevida, o aprofundamento do conhecimento sobre o desenvolvimento e o tratamento dos transtornos neuropsiquiátricos parece ter maior potencial para melhorar o desfecho e a qualidade de vida dos indivíduos que sofreram AVE.

Psychiatric comorbidity and quality of life in patients with post-stroke emotional incontinence

OBJECTIVE

We aimed to investigate the associations of post-stroke emotional incontinence (PSEI) with various psychiatric symptoms and quality of life independent of potential covariates in survivors of acute stroke.

METHODS

A total of 423 stroke patients were assessed within 2 weeks of the index event. Psychiatric symptoms were assessed by the Symptom Checklist-90-Revised (SCL-90-R), which has nine domains comprising Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. Quality of life was measured using the World Health Organization Quality of Life abbreviated form (WHOQOL-BREF), which has four domains related to physical factors, psychological factors, social relationships, and environmental context. Associations of PSEI with scores on the SCL-90-R and WHOQOL-BREF were investigated using pairwise logistic regression model adjustment for potential sociodemographic and clinical covariates.

RESULTS

PSEI was present in 51 (12.1%) patients. PSEI was associated with the Obsessive-Compulsive, Interpersonal Sensitivity, and Hostility symptom dimensions of the SCL-90-R and with the psychological factors and social relationships domains of the WHOQOL-BREF independent of important covariates including previous stroke, stroke severity, and physical disability.

CONCLUSION

PSEI causes some aspects of psychiatric distress and negatively affects psychological and interpersonal quality of life. For patients with PSEI, special attention to psychiatric comorbidity and quality of life is needed, even in the acute stage of stroke.

The neurobiology of moral sense: facts or hypotheses?

One of the most intriguing frontiers of current neuroscientific research is represented by the investigation of the possible neural substrates of morality. The assumption is that in humans an innate moral sense would exist. If this is true, with no doubt it should be regulated by specific brain mechanisms selected over the course of evolution, as they would promote our species' survival. In the last decade, an increasing number of studies have been carried out to explore the neural bases of human morality.The aim of this paper is to present a comprehensive review of the data regarding the neurobiological origin of the moral sense, through a Medline search of English-language articles from 1980 to February 2012.The available findings would suggest that there might be a main integrative centre for the innate morality, in particular the ventromedial prefrontal cortex, with its multiple connections with the limbic lobe, thalamus and brainstem. The subjective moral sense would be the result of an integration of multiple automatic responses, mainly associated with social emotions and interpretation of others' behaviours and intentions.Since converging observations outline how lesions of the proposed neural networks may underlie some personality changes and criminal behaviours, the implications of the studies in this field encompass many areas of the scientific domain.

The neurobiology of moral behavior: review and neuropsychiatric implications

Morality may be innate to the human brain. This review examines the neurobiological evidence from research involving functional magnetic resonance imaging of normal subjects, developmental sociopathy, acquired sociopathy from brain lesions, and frontotemporal dementia. These studies indicate a "neuromoral" network for responding to moral dilemmas centered in the ventromedial prefrontal cortex and its connections, particularly on the right. The neurobiological evidence indicates the existence of automatic "prosocial" mechanisms for identification with others that are part of the moral brain. Patients with disorders involving this moral network have attenuated emotional reactions to the possibility of harming others and may perform sociopathic acts. The existence of this neuromoral system has major clinical implications for the management of patients with dysmoral behavior from brain disorders and for forensic neuropsychiatry.

Violent patient behavior is associated with bodily pain and a high burden on informal caregivers

BACKGROUND

There have been no studies of the relationship between violent behavior by older patients and the physical and mental health of caregivers.

OBJECTIVE

To evaluate the influence of violent behavior in vulnerable elderly patients on bodily pain and caregiver burden in their informal caregivers.

DESIGN

Cross-sectional study.

SUBJECTS

One hundred thirty-seven patients aged > or =40 years old with limited activity and mobility in ten facilities providing home-care services in Japan.

MEASUREMENTS

Degree of caregiver-perceived violent patient behavior and caregivers' bodily pain derived from a self-administered questionnaire, and caregiver burden assessed using scores from both the Burden Index of Caregivers and the Zarit Burden Interview.

RESULTS

The mean age of the 137 patients enrolled in this study was 80.9 years. Of these patients, 31.4% were men, and 34.3% had violent behavior. The mean caregiver age was 65.0 years, and 29.2% were men. Caregivers who looked after violent patients experienced significantly higher odds of having bodily pain [AOR = 3.51; 95% confidence interval (CI): 1.81 to 6.85]. Caregivers of violent patients also reported significant caregiver burden as assessed by the Burden Index of Caregivers (beta-coefficient = 4.92; 95% CI: 1.95 to 7.88) and the Zarit Burden Interview (beta-coefficient = 5.81; 95% CI: 2.92 to 8.70).

CONCLUSIONS

Violent behavior among older patients is associated with significant increases in both physical and psychological burden in their informal caregivers.

Aggressive Behavior in Patients With Stroke: Association With Psychopathology and Results of Antidepressant Treatment on Aggression

OBJECTIVE

To examine, in a post hoc analysis of an antidepressant treatment trial, correlates of irritability and aggression after stroke and changes in irritability scores associated with antidepressant treatment.

DESIGN

Aggressive patients (n=23) were compared with nonaggressive patients (n=69) on numerous measures of psychopathology, poststroke impairment, and neuroimaging findings.

SETTING

All patients were hospitalized at the time of the initial evaluation for acute stroke or for rehabilitation therapy.

PARTICIPANTS

Ninety-two patients from the Iowa City Stroke Study were classified as aggressive or nonaggressive, based on symptoms elicited by the Present State Examination (PSE) and from family or caretaker reports.

INTERVENTION

All patients were randomized to receive nortriptyline, fluoxetine, or placebo using a double-blind methodology.

MAIN OUTCOME MEASURE

The change in aggression score as elicited by the PSE at the beginning and the end of a 12-week treatment trial.

RESULTS

Twenty-five percent (23/92) of patients reported irritability or aggression. Irritable and aggressive patients had higher total PSE scores, Hamilton Depression Rating Scale scores, Hamilton Anxiety Rating Scale (HAMA) scores, and lower Mini-Mental State Examination scores. They also had lesions that were more proximal to the frontal pole. Stepwise regression analysis showed that HAMA scores and proximity of lesion to the frontal pole were significant independent predictors of irritability. Among irritable and aggressive patients with depression who responded to antidepressants, there was a significantly greater reduction in irritability after treatment, compared with patients whose depression did not lessen with treatment.

CONCLUSIONS

Several factors, such as severity of impairment, other psychopathology, and neurobiologic factors, appear to contribute to irritable and aggressive behavior in stroke patients. If depression accompanies aggression, the results of this small study suggest that successful treatment of depression may reduce aggressive behavior.

What frontotemporal dementia reveals about the neurobiological basis of morality

There is evidence that moral behavior is a product of evolution and an innate aspect of the human brain. Functional magnetic resonance studies in normals, investigations of psychopaths, and acquired sociopathy from brain lesions suggest a neurobiology of moral behavior. Reports of sociopathy among patients with frontotemporal dementia (FTD) have provided a further opportunity to clarify the neurobiology of morality. They confirm a morality network that includes the ventromedial frontal cortex, the orbitofrontal cortex, and the amygdalae. The right ventromedial region is critical for the emotional tagging of moral situations, the orbitofrontal cortex responds to social cues and mitigates impulsive reactions, and the amygdalae are necessary for threat detection and moral learning. Alterations in moral behavior in FTD may result from a loss of the emotional label of moral dilemmas, coupled with disinhibited responses. More investigations are needed to fully understand how the brain mediates moral or ethical behavior.

Personality change after stroke: some preliminary observations

OBJECTIVES

To describe changes in personality after stroke and effects on carers.

METHODS

A consecutive series of patients was recruited from hospital admissions with stroke. A novel questionnaire was administered to the patients' main carer at nine months after the stroke to determine their perception of the patients' pre-stroke and post-stroke personality. Personality change was identified by changes in these ratings, and associations between personality change and the following variables explored: emotional disorder in patients and carers (measured using the hospital anxiety and depression scale and a structured psychiatric interview), stroke classification (Oxford community stroke classification), residual disability (Barthel index and Nottingham extended activities of daily living scale), and lesion characteristics on computed tomography (CT).

RESULTS

Carers of 35 patients with stroke took part. Reported changes in personality after stroke included: reduced patience and increased frustration (both p<0.0001, t test of difference), reduced confidence, more dissatisfaction, and a less easy going nature (all p<0.005). Occasionally, aspects of personality change were seen as positive by carers. There were relations between greater personality change and interviewer rated patient depression or anxiety (p<0.001) but not when this was self rated; and between personality change and both emotional disorder in carers (p<0.005) and greater disability (p<0.01) but not CT lesion characteristics.

CONCLUSIONS

Carers commonly perceive personality change in stroke patients. This is associated with self rated emotional distress in the carer. More research is needed to understand what carers mean by "personality change" and what factors contribute to the perceived change.

Consequences of right cerebrovascular accident on emotional functioning: diagnostic and treatment implications

The relationship between lesion location and neuropsychiatric sequelae in stroke patients has been extensively studied. Emotional disorders associated with right hemisphere stroke include depression, anxiety, anger, and/or mania. Pharmacotherapy, electroconvulsive therapy, and/or psychotherapy are common treatments for these disorders. This article reviews the clinical presentations of seven right hemisphere stroke patients. The treatment rationale and course of treatment are described for two of these patients. The aims of this paper are to explore the appropriateness of various assessment tools and treatment modalities for stroke patients as well as to demonstrate the techniques of psychotherapy as applied to the two cases featured in this article. Specific factors that may significantly influence treatment outcome, such as lesion location and degree of cognitive impairment, are considered.

Irritability following traumatic brain injury

This study was undertaken to identify the clinical and pathoanatomical correlates of irritability in patients with closed head injuries. A consecutive series of 66 patients was assessed in hospital and at 3, 6, 9, and 12-month follow-ups. Patients fulfilling criteria for irritability were divided into 2 groups based on the immediate or delayed onset of their irritability and compared with patients without irritability for background characteristics, impairment variables, and lesion characteristics. There were 12 patients (18.2%) with acute onset irritability and 10 (15.1%) with delayed onset irritability. Acute onset irritability patients had a higher frequency of left cortical lesions. Delayed onset irritability patients showed a strong association with poor social functioning and greater impairment in activities of daily living. The findings suggest that post-brain injury irritability may have different causes and treatment in the acute and chronic stages.