Disinhibition

Disinhibition refers to:

• •
  

  Nonaggressive behavior that is socially inappropriate

  
  
• •
  

  The behavior can be verbal, physical, or sexual behavior

Patients who exhibit disinhibition demonstrate poor ability to:

• •
  

  Exercise patience

  
  
• •
  

  Contain impulses

  
  
• •
  

  Conform to societal standards and expectations

  
  
• •
  

  Manage frustration effectively

Disinhibited behavior may occur in the context of emotional dysregulation, in which common observable signs may include labile affect, exaggerated emotional responses, or pathological laughing and crying (please refer to Chapter 35 for more information on emotional dyscontrol after brain injury).

The frequency with which various forms of behavioral dyscontrol occur after brain injury is not well established. The applicable literature is complicated by a challenging nosology wherein many terms are used to capture various behaviors. That said, clinical experience indicates that disinhibition is fairly common in the early recovery stages of moderate to severe TBI. The prevalence of disinhibition after moderate to severe TBI has been reported to range from 12% to 32%.

Assessment of disinhibition must account for:

• •
  

  Cultural considerations

  
  
• •
  

  Presence of painful conditions and associated pain behaviors

  
  
• •
  

  Premorbid personality characteristics

  
  
• •
  

  Other conditions such as mania, psychosis, medications, or substances of abuse that may result in similar types of behaviors

The underlying cause of disinhibited behavior will heavily influence decisions about treatment and management. Assessment of disinhibited behavior can include self-report measures and/or clinician-observation tools. The patient’s level of self-awareness and reliable reporting will often determine the best methods for assessment. Assessment may be facilitated with use of the Neuropsychiatric Inventory (NPI) or its clinician administered version (NPI-C), with both versions capturing applicable data in a disinhibition subscale. ^,

Treatment and management of posttraumatic disinhibition may include pharmacological, behavioral, and environmental management strategies.

Pharmacotherapy for posttraumatic disinhibition includes:

• •
  

  First-line agents as selective serotonin reuptake inhibitors (SSRIs)

  
  
• •
  

  Alternative pharmacotherapy options include anticonvulsants, such as valproate, carbamazepine, and lamotrigine

  
  
• •
  

  Antiandrogenic agents have been reported to be effective for reducing disinhibited sexual behavior.

  
  
• •
  

  Atypical antipsychotics warrant consideration when patients do not respond to other approaches.

Environmental safety measures and behavioral strategies commonly incorporate the use of a behavior modification plan.

Behavior modification plans:

• •
  

  Serve to modify or eliminate the specific dysfunctional behaviors observed in the patient

  
  
• •
  

  Identify internal and external precipitants of the problematic behavior to better inform the use of appropriate behavior modification strategies, such as:

  
  
  
  
  • •
    

    Reinforcement of desired behavior (i.e., not engaging in the disinhibited behavior or replacing it with more socially acceptable behavior)

    
    
  • •
    

    Adverse consequences (e.g., not receiving attention) for the undesired behavior

  
  
  
  
• •
  

  Are most successful when formulated using patient, clinician, and caregiver feedback

  
  
• •
  

  Require consistency across settings and care providers to ensure successful implementation

Aggression

Once again, epidemiology is complicated by a difficult nosology. The term aggression historically has been applied to a broad host of emotional and behavioral problems (e.g., irritability, agitation). More precisely applied, the term aggression refers to verbal or behavioral outbursts or physical violence directed either at objects or people in the environment.

Aggression is a fairly common complication during recovery from moderate to severe TBI. Agitation and aggression within the context of the early posttraumatic confusional state may occur in 30% to 80% of patients. During the late postinjury period after nonpenetrating severe TBI, rates of aggression have been reported to range from 15% to 51%. Studies using the NPI to identify agitation/aggression report frequency of chronic posttraumatic aggression at approximately 20%.

Assessment and management of aggression involves carefully attending to:

• •
  

  Severity of the behavior and impact on others

  
  
• •
  

  Frequency of the behavior

  
  
• •
  

  Differentiation between purposeful and instrumental behavior (i.e., directed at a specific person with effort to obtain a desired outcome) versus reactive and explosive behavior (i.e., involving impulsive actions with no discernable target or identifiable purpose)

  
  
• •
  

  Premorbid psychological factors, such as mood, psychosis, substance use, and personality disorders, which can contribute to an increased incidence of posttraumatic aggression or even be the cause of such behaviors

  
  
• •
  

  Consideration that virtually all behaviors, including aggressive and sexual behaviors, are relevant and adaptive in specific situations, although obviously inappropriate in other contexts

Aggression that occurs in the context of brain injury tends to manifest as impulsive reactions in response to a perceived threat or other unpleasant environmental stimuli (e.g., pain upon dressing change, a stranger assisting with toileting). Aggressive behaviors involving clear targets and discernable objectives should prompt careful consideration in relation to the differential diagnosis and alternative etiologies (i.e., not traumatic injury) for such behaviors.

Anatomically speaking, posttraumatic aggression is most closely associated with injury to the frontal lobes, more specifically the lateral orbitofrontal subcortical circuit (LOFC).

The LOFC:

• •
  

  Supports social comportment and intelligence, including the ability to determine the contextual appropriateness of any given behavior

  
  
• •
  

  Imparts constraints dictated by social norms and consequences on these impulses, facilitating inhibition of aggression and sexual behaviors when circumstances mandate restraint

  
  
• •
  

  When injured, increases the likelihood of misplaced aggression in response to relatively trivial stimuli

Aggressive behaviors are among the most challenging types of posttraumatic conditions to manage. They pose barriers to effective care and treatment because they often result in disruption of supportive relationships with both providers and caregivers and can pose safety threats for the patient, caregivers, and treatment team. Understanding the etiology of the aggression is of utmost importance in determining how best to manage this type of behavioral dyscontrol. There is no one strategy that will effectively manage aggression for all individuals.

The best approach to managing posttraumatic aggression involves:

• •
  

  A multidisciplinary and collaborative effort involving both nonpharmacological and pharmacological strategies

  
  
• •
  

  Early response to behavior when first observed so providers and caregivers can work quickly to develop a management plan before social and legal consequences interfere with access to care

  
  
• •
  

  Thoughtful, front-end assessment that describes the nature, frequency, and severity of the behavior to establish a baseline against which subsequent gains (or losses) may be measured

  
  
• •
  

  Once a baseline has been established, a combination of environmental and behavioral techniques are appropriate first-line interventions

  
  
• •
  

  Behavioral analysis and management, including positive and negative reinforcement, self-controlled time outs, and assertiveness training, should be implemented

  
  
• •
  

  Realistic goal setting that aims to reduce the frequency and severity of undesired behaviors is typically more practical than complete elimination, especially in early periods of recovery and rehabilitation after brain injury

Understandable emotional reactions to aggressive behavior may precipitate reactive responses from caretakers and prescribers. This sometimes results in otherwise helpful treatment strategies being abandoned or altered in response to behaviors that are consistent with (or perhaps even relatively improved from) baseline. Systematic collection of quantifiable data can help avoid such countertherapeutic responses and is facilitated by structured assessment such as the Overt Aggression Scale.

The medication management of aggression typically requires discerning between acute and chronic aggression.

• •
  

  Acute aggression often requires more aggressive interventions to rapidly restore behavioral control and ensure safety.

  
  
• •
  

  Acute aggression may also warrant use of antipsychotics, although these medications are ideally avoided for the purposes of long-term management of persons with TBI.

  
  
  
  
  • •
    

    When antipsychotics are warranted, atypical antipsychotics such as quetiapine, olanzapine, and aripiprazole are preferred because of their more favorable side effect profiles, particularly in relation to cognitive and motoric functioning.

    
    
  • •
    

    If atypical agents fail to afford sufficient benefit, haloperidol becomes a reasonable alternative, although it requires monitoring for akathisia and extrapyramidal side effects.

  
  
  
  
• •
  

  Benzodiazepines may also be indicated to help control acute aggression. Agents with short- or moderate-duration half-lives and no active metabolites are preferred (e.g., lorazepam).

  
  
• •
  

  When using antipsychotics and benzodiazepines, low and frequent dosing rapidly titrated to effectiveness and/or sedation is suggested. Agents should be promptly down titrated and discontinued on restoration of behavioral control.

When aggression manifests as a more chronic sequalae of TBI, initial treatment choices are typically directed by comorbid neuropsychiatric conditions. Common target examples include depression, mood lability, psychosis, anxiety, seizures, or pain.

• •
  

  Aggression cooccurring with depression calls for an antidepressant acting on the serotonin system (e.g. sertraline, escitalopram, or citalopram).

  
  
• •
  

  SSRIs are also the treatment of choice for emotional lability or pathological laughing or crying and anxiety, but buspirone is another reasonable initial option in the setting of anxiety and aggression.

  
  
• •
  

  Anticonvulsants (e.g., carbamazepine and valproic acid) are first-line treatments for aggression that cooccurs with seizures.

  
  
• •
  

  Aggression associated with mania should be managed with mood stabilizers (e.g., valproic acid, carbamazepine, lithium). Lithium does require special consideration because persons with brain injury may have increased susceptibility to neurotoxic side effects. Atypical antipsychotics also may prove helpful in these cases.

  
  
• •
  

  Aggression cooccurring with psychosis calls for an atypical antipsychotic (e.g., quetiapine, olanzapine, or aripiprazole).

  
  
• •
  

  When aggression lacks a clear cooccurring target or other treatments have already been optimized, evidence-based options to target aggression more directly include SSRIs, amantadine, tricyclic antidepressants, buspirone, methylphenidate, valproate, lithium, and the beta-adrenergic receptor antagonists.

Suicide

Suicide is defined as death because of deliberate, self-directed behavior. Self-directed violence (SDV) is a broader term used to encapsulate death by suicide, suicidal behaviors such as preparatory behaviors, suicide attempts, and nonsuicidal self-injurious behaviors such as cutting or burning oneself without the intent to die. Persons with brain injury are at increased risk for self-directed harm, particularly death by suicide, even many years after injury.

There are several possible reasons underlying this association:

• •
  

  The previously described anatomy of aggression is once again applicable, increasing the risk for aggression whether directed outwardly or toward oneself.

  
  
• •
  

  Death by suicide and brain injury share common risk factors such as premorbid psychiatric history and/or substance use disorders, along with demographic factors such as male gender, age, and current or past military service. ^{, ,}

  
  
• •
  

  Persons with brain injury commonly encounter psychosocial stressors such as interpersonal, financial, and legal problems that may increase risk for suicide.

Persons with TBI should be screened for suicide risk during the acute recovery phase, if they are able to engage in the screening process, and as part of ongoing rehabilitative care.

• •
  

  Screening can include brief standardized instruments that include asking directly about suicidal ideation, such as the Patient Health Questionnaire (PHQ-9), in which Item 9 asks, “Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” Studies have demonstrated predictive utility of Item 9 in determining elevated risk for suicide.

  
  
• •
  

  If patients screen positive for suicide risk, a comprehensive evaluation should follow (i.e., past suicidal behavior, characteristics of current ideation, and intent and relevant risk factors and protective factors).

  
  
• •
  

  Risk should be stratified by temporality and severity (i.e., level of acute risk and chronic risk).

  
  
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  A management plan for mitigating risk in the current care setting must follow. Examples of management strategies for moderate to high acute risk include transfer to an inpatient psychiatric unit or adjustments to the current care environment such as line-of-site observation and removing sharp objects.

After immediate safety concerns are addressed, providers may consider approaching suicidal thinking and behavior with a combination of both pharmacological and therapeutic interventions. If evidence of thoughts or behavior related to SDV is observed or reported in the context of a diagnosed psychiatric condition, for example, a mood or psychotic disorder, pharmacological management of the underlying condition may be an appropriate first-line approach. Behavioral interventions can help mitigate risk of self-directed harm after brain injury.

Safety planning is an essential component of suicide prevention when working with individuals at increased risk for suicide. The safety plan is developed collaboratively with the patient to identify warning signs that occur at the onset of a crisis and highly personal, individualized coping skills and resources to use both to prevent crises and manage to crises more effectively when they occur. Such plans are especially important for persons with TBI because they often struggle with cognitive deficits that compromise the ability to remember and implement coping strategies in a timely or effective fashion.

Several evidence-based treatments may be effective in reducing risk of death by suicide for persons with TBI.

Evidence-based therapies that have demonstrated reduction of suicide risk include:

• •
  

  Cognitive therapy for suicide prevention (CT-SP)

  
  
• •
  

  Cognitive behavioral therapy (CBT)

  
  
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  Dialectical behavioral therapy (DBT)

  
  
• •
  

  Problem-solving therapy (PST)

There are also more recently developed treatments that demonstrate empirical support for reducing suicide risk specifically in brain injury populations.

Examples include:

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  Window to Hope (WtoH), an approach that incorporates behavioral activation, cognitive restructuring, problem solving, and relapse prevention

  
  
• •
  

  Problem-Solving Therapy for Suicide Prevention (PST-SP), a brief intervention that focuses on using problem-solving skills and coping strategies to enhance safety planning

Both approaches target hopelessness associated with distress in persons with brain injury. It is recommended that any therapeutic intervention for suicide prevention after brain injury aims to address the common key presenting problems that lead to distress and result in elevated risk: ineffective coping, poor problem solving, social isolation, and a lack of pleasant or rewarding activities.

Review questions

• 1.
  

  When assessing and diagnosing posttraumatic disinhibition, providers must consider premorbid personality characteristics, pain conditions and pain behaviors, and

  
  
  
  
  • a.
    

    Age

    
    
  • b.
    

    Cultural factors

    
    
  • c.
    

    Blood type

    
    
  • d.
    

    Length of posttraumatic amnesia

  
  
  
  
• 2.
  

  A patient presents with disinhibited behavior involving inappropriate comments to members of the care team about their physical appearance. An appropriate behavior modification plan would include

  
  
  
  
  • a.
    

    rewarding a day without such comments with a movie selected by the patient.

    
    
  • b.
    

    designating one provider as the individual who will respond to such comments.

    
    
  • c.
    

    eliminating breaks or free time until the patient no longer makes inappropriate comments.

    
    
  • d.
    

    administering a benzodiazepine whenever comments are observed.

  
  
  
  
• 3.
  

  Which of these is an appropriate first-line pharmacological treatment for posttraumatic disinhibition?

  
  
  
  
  • a.
    

    Carbamazepine

    
    
  • b.
    

    Quetiapine

    
    
  • c.
    

    Electroconvulsive therapy

    
    
  • d.
    

    Sertraline

  
  

Answers on page 398.

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Available on ExpertConsult.com

• 4.
  

  Which of these descriptions of behavior most likely demonstrates aggression resulting from brain injury?

  
  
  
  
  • a.
    

    Violence for hire

    
    
  • b.
    

    An act of revenge against a former employer

    
    
  • c.
    

    Forcefully resisting assistance from a healthcare worker

    
    
  • d.
    

    Refusing visits from family and caretakers

  
  
  
  
• 5.
  

  A patient presents with posttraumatic confusion 4 days postinjury. The patient becomes violent when nursing staff attempt to dress wounds with bandages, ultimately preventing proper wound care. An appropriate intervention would include

  
  
  
  
  • a.
    

    social skills education.

    
    
  • b.
    

    escitalopram.

    
    
  • c.
    

    lithium.

    
    
  • d.
    

    quetiapine.

  
  
  
  
• 6.
  

  Posttraumatic aggression is most closely associated with injury to

  
  
  
  
  • a.
    

    lateral orbitofrontal subcortical circuit (LOFC).

    
    
  • b.
    

    cerebellar cortex.

    
    
  • c.
    

    vagus nerve.

    
    
  • d.
    

    temporal lobes.

  
  
  
  
• 7.
  

  Which of these is one reason that persons with brain injury are at increased risk for suicide?

  
  
  
  
  • a.
    

    Increased access to opiates

    
    
  • b.
    

    Shared premorbid risk factors for both brain injury and suicide

    
    
  • c.
    

    There are no evidence-based treatments to address hopelessness after TBI.

    
    
  • d.
    

    Persons with brain injury are more likely to own firearms.

  
  
  
  
• 8.
  

  When should persons with brain injury first be screened for suicide risk?

  
  
  
  
  • a.
    

    When Glasgow Coma Scale (GCS) score reaches 9 or above

    
    
  • b.
    

    During acute recovery if able to engage

    
    
  • c.
    

    At end of rehabilitative care

    
    
  • d.
    

    When family and caregivers provide consent to screen

  
  
  
  
• 9.
  

  A safety plan includes which of the following?

  
  
  
  
  • a.
    

    Treatment goals

    
    
  • b.
    

    Individualized coping skills

    
    
  • c.
    

    Daily medications list

    
    
  • d.
    

    Locations of nearest fire exits

  
  
  
  
• 10.
  

  Any therapeutic approach to reducing suicidal ideation and behavior after brain injury should include a focus on

  
  
  
  
  • a.
    

    problem-solving skills.

    
    
  • b.
    

    describing the injury event in detail.

    
    
  • c.
    

    repairing familial relationships.

    
    
  • d.
    

    return to driving.