Mild Traumatic Brain Injury and Aggression, Impulsivity, and History of Other- and Self-Directed Aggression

Agitation in cognitive disorders: Progress in the International Psychogeriatric Association consensus clinical and research definition

BACKGROUND

The International Psychogeriatric Association (IPA) published a provisional consensus definition of agitation in cognitive disorders in 2015. As proposed by the original work group, we summarize the use and validation of criteria in order to remove "provisional" from the definition.

METHODS

This report summarizes information from the academic literature, research resources, clinical guidelines, expert surveys, and patient and family advocates on the experience of use of the IPA definition. The information was reviewed by a working group of topic experts to create a finalized definition.

RESULTS

We present a final definition which closely resembles the provisional definition with modifications to address special circumstances. We also summarize the development of tools for diagnosis and assessment of agitation and propose strategies for dissemination and integration into precision diagnosis and agitation interventions.

CONCLUSION

The IPA definition of agitation captures a common and important entity that is recognized by many stakeholders. Dissemination of the definition will permit broader detection and can advance research and best practices for care of patients with agitation.

Longitudinal Biochemical and Behavioral Alterations in a Gyrencephalic Model of Blast-Related Mild Traumatic Brain Injury

Blast-related traumatic brain injury (bTBI) is a major cause of neurological disorders in the U.S. military that can adversely impact some civilian populations as well and can lead to lifelong deficits and diminished quality of life. Among these types of injuries, the long-term sequelae are poorly understood because of variability in intensity and number of the blast exposure, as well as the range of subsequent symptoms that can overlap with those resulting from other traumatic events (e.g., post-traumatic stress disorder). Despite the valuable insights that rodent models have provided, there is a growing interest in using injury models using species with neuroanatomical features that more closely resemble the human brain. With this purpose, we established a gyrencephalic model of blast injury in ferrets, which underwent blast exposure applying conditions that closely mimic those associated with primary blast injuries to warfighters. In this study, we evaluated brain biochemical, microstructural, and behavioral profiles after blast exposure using in vivo longitudinal magnetic resonance imaging, histology, and behavioral assessments. In ferrets subjected to blast, the following alterations were found: 1) heightened impulsivity in decision making associated with pre-frontal cortex/amygdalar axis dysfunction; 2) transiently increased glutamate levels that are consistent with earlier findings during subacute stages post-TBI and may be involved in concomitant behavioral deficits; 3) abnormally high brain N-acetylaspartate levels that potentially reveal disrupted lipid synthesis and/or energy metabolism; and 4) dysfunction of pre-frontal cortex/auditory cortex signaling cascades that may reflect similar perturbations underlying secondary psychiatric disorders observed in warfighters after blast exposure.

Impulsivity and Psychiatric Diagnoses as Mediators of Suicidal Ideation and Suicide Attempts Among Veterans With Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) is a risk factor for suicide, but questions related to mechanisms remain unanswered. Impulsivity is a risk factor for suicide and is a common sequela of TBI. The authors explored the relationships between TBI and both suicidal ideation and suicide attempts and explored whether impulsivity and comorbid psychiatric diagnoses mediate these relationships.

METHODS

This cross-sectional retrospective chart review study included 164 veterans enrolled in a previous study. Sixty-nine veterans had no TBI history, and 95 had a TBI history (mild, N=44; moderate, N=13; severe, N=12; and unclear severity, N=26). To examine the associations between TBI and suicidal ideation or suicide attempts, as well as potential mediators of these relationships, chi-square tests, t tests, and logistic regression models were used.

RESULTS

Unadjusted analyses indicated that veterans with TBI were more likely to report suicidal ideation; however, in analyses controlling for mediators, this relationship was no longer significant. Among veterans with TBI, suicidal ideation was related most strongly to high impulsivity (odds ratio=15.35, 95% CI=2.43-96.79), followed by depression (odds ratio=5.73, 95% CI=2.53-12.99) and posttraumatic stress disorder (odds ratio=2.57, 95% CI=1.03-6.42). TBI was not related to suicide attempts, yet suicide attempts were related to high impulsivity (odds ratio=6.95, 95% CI=1.24-38.75) and depression (odds ratio=3.89, 95% CI=1.56-9.40).

CONCLUSIONS

These findings suggest that impulsivity, followed by psychiatric diagnoses, most strongly mediate the relationships between TBI and both suicidal ideation and suicide attempts. Impulsivity may be mechanistically related to, and serve as a future treatment target for, suicidality among veterans with TBI.

Mediating effects of impulsivity and alexithymia in the association between traumatic brain injury and aggression in incarcerated males

Studies suggest both alexithymia and impulsivity (partially) explain aggressive behavior in traumatic brain injury (TBI) patients, but none of these studies use both questionnaire and performance-based measures as recommended, nor simultaneously investigate both impulsivity and alexithymia. The available studies therefore likely miss part of the constructs of alexithymia and impulsivity, and do not comprehensively assess the mediating effects of both constructs in the relationship between TBI and aggression. A sample of N = 281 incarcerated individuals were recruited from Dutch penitentiary institutions, and completed the Buss Perry Aggression Questionnaire (aggression), BIS-11 (impulsivity) and Toronto Alexithymia Scale-20 (alexithymia) questionnaires, as well as a stop-signal task and an emotion recognition paradigm. Several multiple mediation analyses were conducted using structural equation modelling, to assess the viability of a causal theoretical model of aggression. The final planned models were the original models with a good fit with the data (comparative fit index > 0.95, root mean square error of approximation and Standardized root mean square residual < 0.05), and results indicate that only questionnaire-based impulsivity mediated the relationship between TBI and aggression. TBI was unrelated to alexithymia, stop-signal or emotion recognition performance. Aggression was predicted by both alexithymia and impulsivity, but not by the performance measures. Post hoc analyses shows that alexithymia moderates the relationship between impulsivity and aggression. These results imply that aggressive incarcerated individuals showing impulsive behavior should be screened for TBI, since TBI is often overlooked or misdiagnosed, and indicate that both impulsivity and alexithymia are potential focus points for aggression reduction treatment in TBI patients.

Self-reported traumatic brain injury in a sample of impulsive violent offenders: neuropsychiatric correlates and possible "dose effects"

Background

Traumatic brain injury (TBI) is a major public health problem that may be associated with numerous behavioral problems, including impulsivity, aggression and violence. Rates of self-reported TBI are high within offender populations, but the extent to which TBI is causally implicated in causing illegal behavior is unclear. This study examined the psychological and functional correlates of histories of traumatic brain injury in a sample of impulsive violent offenders.

Methods

Study participants, all men, had been recruited to participate in a randomized controlled trial of sertraline to reduce recidivism. Study entry criteria were an age of at least 18 years, a documented history of two or more violent offenses and a score of 70 or above on the Barratt Impulsiveness Scale. An extensive list of standardized questionnaires was administered to obtain information on previous TBI and other neuropsychiatric conditions or symptoms.

Results

In the sample of 693 men, 66% were aged between 18 and 35 years old, and 55% gave a history of TBI ("TBI+"). Overall, 55% of study participants reported at least one TBI. High levels of neuropsychiatric symptomatology were reported. In 75% of TBI+ individuals, their most severe TBI (by self-report) was associated with loss of consciousness (LOC) < 30 min. Compared to TBI- (those without history of TBI) participants, TBI+ individuals were more impulsive (Eysenck Impulsivity), irritable, angry, and reported higher levels of assaultive behavior, depressive symptomology, alcohol use disorder, suicidal ideation, suicide attempts, and lower quality of life. Potential "dose effects" of TBI severity and frequency in terms of neuropsychiatric symptomatology were identified.

Conclusion

Like other studies of offender populations, single and multiple TBIs were very common. The associations of TBI, TBI severity, and TBI frequency (i.e., TBI "burden") with adverse neuropsychiatric phenomena suggest TBI contributes importantly to offender morbidity but the select nature of the sample and cross-sectional study design constrain the interpretation of these findings.

Gender Differences in Adolescents' Affective Symptoms and Behavioral Disorders After Mild Traumatic Brain Injury

OBJECTIVE

Mild traumatic brain injuries (mTBI) are considered self-limiting and full recovery is expected. Recent studies identify deficits persisting years after mTBI. Large-scale prospective data permit testing the hypothesis that mTBI increases incidence of affective and behavioral symptoms after new, past , or new and past mTBI.

SETTING

The study involved secondary analyses of survey responses from the Adolescent Brain Cognitive Development (ABCD) Study.

PARTICIPANTS

Adolescents in the ABCD Study ( n = 11 869; Wave 1, aged 9-10 years; Wave 2, aged 11-12 years) whose parents reported a new ( n = 157), past ( n = 1318), or new and past ( n = 50) mTBI on the Ohio State University Traumatic Brain Injury Identification Method short form were compared with controls who had no history of mTBI ( n = 9,667).

DESIGN

Multivariable binary logistic regression models examined associations between a new, past, or new and past mTBI and current affective (aggression, depression, anxiety) and behavioral (somatic, thought, social, attention, attention deficit hyperactivity disorder, conduct) disorders while controlling for demographic factors and baseline symptoms.

MAIN MEASURES

The primary measure was parental reports of psychiatric and behavioral symptoms on the Child Behavior Checklist.

RESULTS

Girls exhibited no significant effects after a new mTBI, although a past mTBI increased anxiety (adjusted odds ratios [aOR] = 1.83, 95% confidence interval [CI: 1.15-2.90]) and attention (1.89 [1.09-3.28]) problems. Girls with new and past mTBIs reported elevated anxiety (17.90 [4.67-68.7]), aggression (7.37 [1.49-36.3]), social (9.07 [2.47-33.30]), thought (7.58 [2.24-25.60]), and conduct (6.39 [1.25-32.50]) disorders. In boys, new mTBI increased aggression (aOR = 3.83, 95% CI [1.42-10.30]), whereas past mTBI heightened anxiety (1.91 [1.42-2.95]), but new and past mTBIs had no significant effects.

CONCLUSION

Adolescents are at greater risk of affective and behavioral symptoms after an mTBI. These effects differ as a function of gender and time of injury. Extended screening for mTBI history and monitoring of affective and behavioral disorders after mTBI in adolescents are warranted.

Potential Biomarkers of Impulsivity in Mild Traumatic Brain Injury: A Pilot Study

Very few studies have investigated cognition and impulsivity following mild traumatic brain injury (mTBI) in the general population. Furthermore, the neurobiological mechanisms underlying post-TBI neurobehavioral syndromes are complex and remain to be fully clarified. Herein, we took advantage of machine learning based-modeling to investigate potential biomarkers of mTBI-associated impulsivity. Twenty-one mTBI patients were assessed within one-month post-TBI and their data were compared to 19 healthy controls on measures of impulsivity (Barratt Impulsiveness Scale - BIS), executive functioning, episodic memory, self-report cognitive failures and blood biomarkers of inflammation, vascular and neuronal damage. mTBI patients were significantly more impulsive than controls in BIS total and subscales. Serum levels of sCD40L, Cathepsin D, IL-4, Neuropilin-1, IFN-α2, and Copeptin were associated with impulsivity in mTBI patients. Besides showing that mTBI are associated with impulsivity in non-military people, we unveiled different pathophysiological pathways potentially implicated in mTBI-related impulsivity.

Childhood and parental characteristics of adults with DSM-5 intermittent explosive disorder compared with healthy and psychiatric controls

BACKGROUND

Intermittent Explosive Disorder (IED) is a disorder primarily of aggression, defined by recurrent behavioral outbursts out of proportion to provocations or stressors. IED first appears in childhood and adolescence. This study examines the underlying childhood environment of those with IED, particularly familial and school-related factors.

METHODS

Adult participants from a larger study completed diagnostic assessments and a battery of self-report measures. Group assignment was based on the assessment: 1) IED diagnosis; 2) non-IED psychiatric diagnosis; and 3) no significant psychiatric history. Groups were compared on factors of parental demographics, intrafamilial aggression, lifetime syndromal and personality diagnoses, neurodevelopmental and learning difficulties, childhood peer relationships, and juvenile legal issues.

RESULTS

Significant patterns emerged specific to IED for not being raised by both parents, greater physical aggression to participant, and greater degree of fighting with peers by age ten.

LIMITATIONS

The retrospective, and cross-sectional, nature of the study, which prevent the making of causal inferences, and the basic nature of the questions asked of participants which limit a more nuanced interpretation of the data. A further limitation is bias associated with self-reported responses.

CONCLUSIONS

Results suggest the prevalence childhood adversaries may be linked with IED; the childhood environment of those with IED likely is substantially more tumultuous than individuals with or without other psychiatric disorders.

Personality disorder and mild traumatic brain injury

Mild traumatic brain injury (mTBI) poses risk to the neurocognitive, emotional, and financial well-being of affected individuals. While aggression and impulsivity have been examined in relation to mTBI, little work has been done to evaluate the relationship between history of mTBI and personality disorder (PD). The authors examined the associations between history of mTBI and PD in a control group without history of mTBI (N = 1189) and individuals with history of mTBI (N = 267). Results demonstrated that any PD diagnosis is a significant risk factor for mTBI (p < 0.001). Cluster B diagnoses, particularly borderline and antisocial PD, were independently significant risk factors for mTBI. These data suggest a role for screening for a history of mTBI in patients with PDs and associated traits.

Associations between interpersonal violence victimisation and concussions among US college students

Interpersonal violence is common on college campuses and is associated with many adverse health outcomes; however, it remains unknown whether experiencing interpersonal violence victimisation is associated with concussions. The aim of this study was to estimate the associations between interpersonal violence, including emotional abuse, physical abuse and sexual assault, and concussions among a large, diverse sample of college students. We analysed cross-sectional data from the 2018-2019 national (US) Healthy Minds Study (N = 1,478). Multiple logistic regression analyses were conducted to estimate the association between interpersonal violence victimisation (any violence victimisation, emotional abuse, physical abuse and sexual assault) and concussion history (any concussion, diagnosed concussion and undiagnosed concussion), while adjusting for potential confounders. Analyses were conducted among the overall sample and separately by male and female participants. Results showed patterns of significant associations between interpersonal violence victimisation and concussions among the overall sample and among male and female participants. Among the overall sample, any interpersonal violence victimisation (adjusted odds ratio [AOR] 1.45, 95% confidence interval [CI] 1.13-1.88), emotional abuse (AOR 1.36, 95% CI 1.06-1.76), physical abuse (AOR 1.61, 95% CI 1.07-2.44) and sexual assault (AOR 2.17, 95% CI 1.44-3.26) were associated with higher odds of any concussion history. Sexual assault victimisation had the strongest association with any concussion history among male (AOR 1.96, 95% CI 1.04-3.71) and female (AOR 2.96, 95% CI 1.62-5.43) participants. These results expand on prior interpersonal violence and concussion research by showing an association with multiple victimisation measures among a large and diverse sample of college students. Medical professionals should screen for concussions among college students who experience emotional abuse, physical abuse and sexual assault to provide appropriate guidance. Information on the symptoms of concussions should be incorporated into campus violence awareness and prevention efforts.

The prevalence, characteristics, and psychiatric correlates of traumatic brain injury in incarcerated individuals: an examination in two independent samples

PRIMARY OBJECTIVE

Identify the prevalence, characteristics, and psychological correlates of traumatic brain injury (TBI) among incarcerated individuals.

RESEARCH DESIGN

Three aims: (1) Determine the prevalence and characteristics of TBI in 1469 adults incarcerated in Wisconsin state prisons (1064 men, 405 women); (2) Characterize the relationship between mild TBI and mental illness in a sub-sample of men and women; (3) Reproduce the findings from Aim 1 and Aim 2 in an independent sample of 1015 adults incarcerated in New Mexico state prisons (600 men, 415 women).

METHODS AND PROCEDURES

Standardized TBI assessment with structured clinical interviews and self-report questionnaires.

MAIN OUTCOMES AND RESULTS

Rates of TBI were approximately five times greater than the general population, with a substantially higher rate of TBI caused by assault. In the Wisconsin sample, mild TBI was associated with greater levels of post-traumatic stress disorder (PTSD) among women (but not among men). In the New Mexico sample, TBI of any severity was associated with greater levels of major depressive disorder (MDD) among women (but not among men).

CONCLUSIONS

This study thus provides novel data on TBI and its correlates among individuals incarcerated in state prisons, and highlights a specific treatment need within the prison population.

Closing the gap: unmet needs of individuals with impulsive aggressive behavior observed in children and adolescents

Impulsive aggressive (IA, or impulsive aggression) behavior describes an aggregate set of maladaptive, aggressive behaviors occurring across multiple neuropsychiatric disorders. IA is reactive, eruptive, sudden, and unplanned; it provides information about the severity, but not the nature, of its associated primary disorder. IA in children and adolescents is of serious clinical concern for patients, families, and physicians, given the detrimental impact pediatric IA can have on development. Currently, the ability to properly identify, monitor, and treat IA behavior across clinical populations is hindered by two major roadblocks: (1) the lack of an assessment tool designed for and sensitive to the set of behaviors comprising IA, and (2) the absence of a treatment indicated for IA symptomatology. In this review, we discuss the clinical gaps in the approach to monitoring and treating IA behavior, and highlight emerging solutions that may improve clinical outcomes in patients with IA.

Psychotropic and pain medication use in individuals with traumatic brain injury-a Swedish total population cohort study of 240 000 persons

OBJECTIVE

To examine psychotropic and pain medication use in a population-based cohort of individuals with traumatic brain injury (TBI), and compare them with controls from similar backgrounds.

METHODS

We assessed Swedish nationwide registers to include all individuals diagnosed with incident TBI between 2006 and 2012 in hospitals or specialist outpatient care. Full siblings never diagnosed with TBI acted as controls. We examined dispensed prescriptions for psychotropic and pain medications for the 12 months before and after the TBI.

RESULTS

We identified 239 425 individuals with incident TBI, and 199 658 unaffected sibling controls. In the TBI cohort, 36.6% had collected at least one prescription for a psychotropic or pain medication in the 12 months before the TBI. In the 12 months after, medication use increased to 45.0%, an absolute rate increase of 8.4% (p<0.001). The largest post-TBI increases were found for opioids (from 16.3% to 21.6%, p<0.001), and non-opioid pain medications (from 20.3% to 26.6%, p<0.001). The majority of prescriptions were short-term; 20.6% of those prescribed opioids and 37.3% of those with benzodiazepines collected prescriptions for more than 6 months. Increased odds of any psychotropic or pain medication were associated with individuals before (OR: 1.62, 95% CI: 1.59 to 1.65), and after the TBI (OR: 2.30, 95% CI: 2.26 to 2.34) as compared with sibling controls, and ORs were consistently increased for all medication classes.

CONCLUSION

High rates of psychotropic and pain medications after a TBI suggest that medical follow-up should be routine and review medication use.

Sensation-Seeking and Impulsivity in Athletes with Sport-Related Concussion

PURPOSE OF REVIEW

Sport-related concussion (SRC) is a significant public health problem. Understanding the behavioral and personal factors that influence risk and incidence of SRC is critically important for appropriate care and management. Sensation-seeking and impulsivity have been posited to be two such factors that may be significantly associated with SRC. We performed a focused review of recent evidence of the relationships between sensation-seeking and impulsivity in athletes with SRC.

RECENT FINDINGS

While the research is relatively limited, extant findings demonstrate a significant relationship between sensation-seeking and contact sport participation and risk of prior and future SRC. Impulsivity appears to be common among athletes competing in high contact sports and may contribute to neural and functional brain changes following SRC; however, causal relationships between impulsivity, contact sport participation, and SRC have not been demonstrated. Both sensation-seeking and impulsivity are significantly associated with SRC in collegiate athletes. Interventions designed to ameliorate high levels of these constructs may prove to be beneficial avenues to reducing SRC risk and improving patient care and outcomes.

The Relationship between Sport-Related Concussion and Sensation-Seeking

Sensation-seeking, or the need for novel and exciting experiences, is thought to play a role in sport-related concussion (SRC), yet much remains unknown regarding these relationships and, more importantly, how sensation-seeking influences SRC risk. The current study assessed sensation-seeking, sport contact level, and SRC history and incidence in a large sample of NCAA collegiate athletes. Data included a full study sample of 22,374 baseline evaluations and a sub-sample of 2037 incident SRC. Independent samples t-test, analysis of covariance, and hierarchical logistic regression were constructed to address study hypotheses. Results showed that (1) among participants without SRC, sensation-seeking scores were higher in athletes playing contact sports compared to those playing limited- or non-contact sports (p < 0.001, R² = 0.007, η²_p = 0.003); (2) in the full study sample, a one-point increase in sensation-seeking scores resulted in a 21% greater risk of prior SRC (OR = 1.212; 95% CI: 1.154-1.272), and in the incident SRC sub-sample, a 28% greater risk of prior SRC (OR = 1.278; 95% CI: 1.104-1.480); (3) a one-point increase in sensation-seeking scores resulted in a 12% greater risk of incident SRC among the full study sample; and (4) sensation-seeking did not vary as a function of incident SRC (p = 0.281, η²_p = 0.000). Our findings demonstrate the potential usefulness of considering sensation-seeking in SRC management.

Catastrophic consequences: can the feline parasite Toxoplasma gondii prompt the purrfect neuroinflammatory storm following traumatic brain injury?

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide; however, treatment development is hindered by the heterogenous nature of TBI presentation and pathophysiology. In particular, the degree of neuroinflammation after TBI varies between individuals and may be modified by other factors such as infection. Toxoplasma gondii, a parasite that infects approximately one-third of the world’s population, has a tropism for brain tissue and can persist as a life-long infection. Importantly, there is notable overlap in the pathophysiology between TBI and T. gondii infection, including neuroinflammation. This paper will review current understandings of the clinical problems, pathophysiological mechanisms, and functional outcomes of TBI and T. gondii, before considering the potential synergy between the two conditions. In particular, the discussion will focus on neuroinflammatory processes such as microglial activation, inflammatory cytokines, and peripheral immune cell recruitment that occur during T. gondii infection and after TBI. We will present the notion that these overlapping pathologies in TBI individuals with a chronic T. gondii infection have the strong potential to exacerbate neuroinflammation and related brain damage, leading to amplified functional deficits. The impact of chronic T. gondii infection on TBI should therefore be investigated in both preclinical and clinical studies as the possible interplay could influence treatment strategies.

Traumatic Brain Injury and Psychiatric Co-Morbidity in the United States

The objective of the present study was to provide a nationally representative psychiatric epidemiologic investigation of traumatic brain injury (TBI) and its co-morbid conditions. Data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC-III) collected between 2012 and 2013 was used. Results indicated that TBI was significantly associated with any lifetime mental health (AOR = 2.32, 95% CI = 1.65-3.70), substance use disorder (AOR = 1.57-1.01-2.42), and violent (AOR = 1.65, 95% CI = 1.03-2.65) and nonviolent (AOR = 1.84, 95% CI = 1.25-2.70) criminal behaviors. In our study, TBI was highly comorbid with psychiatric disorders and especially antisocial behaviors, both violent and non-violent.