TBI and Aggression – the comorbid mix

More thoughts on Aggression, for the series Then And Now – Managing TBI Issues Over the Long Term

As Google shows, TBI and Aggression are the subject of a whole lot of research and discussion. There are close to a million results when you search for +tib+aggresssion.

Physical aggression, verbal aggression… They’re two different things, but they still have some common origins. And how they manifest can depend on the individual, the nature of their injury, their environment and stressors, as well as a ton of other issues.

Aggression is one of the toughest aspects of TBI, for individuals, families, and society as a whole. Plenty of incarcerated violent offenders have a history of traumatic brain injury, so we ultimately all pay for those injuries, to one extent or another.

I’ve been looking through a great presentation from the Defense Centers of Excellence called Mild Traumatic Brain Injury & Co-Occurring Disorders: Scope of the Problem. It talks about the different issues that show up along with TBI among veterans seeking medical help.

From the presentation:

• Of the veterans presenting to a polytrauma network site in Lew’s study (2009), 81.5 percent had more than one diagnosis and 42.1 percent had three co-occurring diagnosis, including pain, post-traumatic stress disorder (PTSD), and post-concussion syndromes.
• In another study by Ruff and colleagues (2008), approximately 66 percent of veterans presenting with headache and TBI symptoms had cognitive deficits on examination, more severe and frequent headaches, more reports of pain, higher rates of PTSD, and impaired sleep with nightmares.
• Veterans with positive TBI screens are more likely to have a diagnosis of PTSD, depression, and substance abuse disorder.

I’m not a veteran, but I can attest to the presence of plenty of issues that would qualify as additional diagnoses. The pain, headaches, insomnia, memory issues, post-concussion stuff, not to mention tinnitus, chronic fatigue, irritability, anxiety… all of this mixed in with a bit of PTSD. I could go on. In fact, it seems odd to even break it all out into separate diagnoses.  It’s all just TBI, from where I’m sitting.

Of course, it could also be other things. Just Plain Life has had its effect. I can’t lay everything at the feet of traumatic brain injury, I suppose.

Anyway, looking at the many things that come up in combination with TBI, I can see in my own life how it all connects and can really feed into my anger and aggression issues. TBI and its host of related issues can really put you on the defensive, which can translate to some pretty aggressive behavior.

I have noticed in my own life that the times when I have been the most aggressive, were the times when I was feeling the most vulnerable, helpless, exposed. I’ve felt overwhelmed and put-upon like nobody’s business. Like an animal backed into a corner, with nowhere to run. So much was going on, and I felt like I was getting farther and farther behind, unable to follow what’s going on, because everyone was going too fast for me to keep up, or they were not letting me get clear on what’s happening, so I was losing my grip on what’s happening.  And my head would get going about all the awful things that are about to happen because I’m not following what’s happening around me. And I would freak.

See, here’s the thing — TBI can put a huge strain on your overall system. Let’s not even think about the cognitive issues, for a minute. When you’ve got intense balance issues as well as problems with light and sound, and you’re prone to fatigue (which just accentuates the sensory issues), just getting through the morning can be a challenge. And the part of our bodies which requires a whole lot of energy is our brain. Even people with fully functioning, neurologically intact brains require a ton of energy to keep functioning normally. So, when you’ve got even more demands on you — physically — it can impact your cognition as well.

Here’s a diagram of how I see it happening in my own life:

 

TBI-Aggression Flow - Click to see a larger version

It’s all connected – body, mind, spirit – and when the body is taking a bigger hit from all the extra demands of just standing up and walking across a brightly lit room filled with loudly talking people, something’s gotta give.

Problem is, with TBI, one of the results of fatigue is an increased irritability. Heck, even without fatigue, with TBI, you tend to get an increase in irritability. And that irritability, coupled with any impulse control issues you might have, can lead to outbursts.

On top of that (if you’re like me) and you’re up in your head about your interpretation of what’s going on (which usually means something really bad and threatening, like people hate you and want to get rid of you — and is usually completely wrong), your impaired thinking process can result in some behavior choices that are not only inappropriate, but completely uncalled-for.

The outbursts can take an ugly turn, because now you’re not only struggling to keep up and defend against the perceived threat of an overwhelming situation, but you’re also defending yourself against the perceived threat of someone deliberately trying to get you. And when you’re threatened on that level, anything you do and say to defend yourself from everyone who is out to get you can feel 1000% justified.

Nobody else sees it that way, however. As far as they’re concerned, you’re just unstable and irrational and possibly dangerous.

Getting to the bottom of what’s going on and keeping the cycle from escalating can be quite a challenge. It would be great if we could say, “Okay, just stop this and this, and everything will be fine.” But it’s a complex interaction of factors that feed into the aggression mix. Comorbid factors. Stuff that happens as a result of TBI. Stuff that happened that led to the TBI. Trauma. Pain. Emotions. Everything.

Perhaps that’s the best protection, however — just the awareness of the fact that dealing with TBI-related aggression is not some easy-peasey piece-o-cake, and that it demands some pretty regular management strategies to keep on top of things. Managing comorbid symptoms and aggression are lifestyle issues — they are intimately related to how we live our lives as a whole — not just how we behave when we’re standing in line at the post office.

A different kind of brain injury

The medial temporal lobe

During my morning exercise bike ride, I checked out The Concussion Blog on my PDA (thankfully, there’s a mobile version of the blog, so I don’t have to scroll through all kinds of formatting stuff), and I came across a few interesting threads that might have some bearing on each other.

The first was a comment at the post about how Nowinski is leaning towards the “more rest” position of Omalu, and concussion — while widely attributed to the brain being shaken inside the skull — can also be attributed to jaw impacts

where the brain hits off the side of the inner skull like a piece of jello, here the medial temporal lobe is traumatized when the end of the jawbone pierces the temporal bone. The end of the jawbone rests on the skull base, cushioned by a dime sized piece of cartilage, once this cushioning element is displaced, it becomes dangerous. Its been documented in boxers with a “glass jaw”, when this cartilage disk slips out of place, it creates a bone on bone condition allowing hard bone to hammer the area of the medial temporal lobe where CTE manifest. This is diagnosable and documented in research with boxers and now NFL and NHL players.

Hmm. I had heard some discussion about how mouthguards supposedly guard against concussion. I’ve heard a number of people dismiss mouthguards, saying that they can’t protect against the brain banging againt the inside of the skull, and I myself have been skeptical. But seeing it explained — and taking a look at the location of the jaw in relation to the medial temporal lobe — I’m more convinced. Especially after reading that CTE manifests in that exact area.

This is getting my attention.

What’s also getting my attention is another post over at The Concussion Blog where fighting in the NFL is discussed. And after watching some hockey over the past week and seeing all the fights that are not stopped by the refs (and are egged on and celebrated by cheering fans), I wonder how much these fights — with more than a few hits to the jaw — contribute to the cumulative risk of concussion.

Let’s be clear about something — concussions/head injuries/TBIs all add up. Their effect is cumulative. And I can’t see how encouraging and allowing all the fistfights to escalate and play themselves out until someone goes down on the ice can help matters. Concussion awareness, I think, needs to reach beyond the “head hitting against the bony insides of the skull” and expand into the effects of the jaw hitting against the medial temporal lobe. And I’d also like to see/hear more consideration of not only the dangers of sports, when it comes to concussion, but the dangers of fights and getting clocked in the jaw, time after time.

I watched the March 5th ‘The Hotstove’ where Mike Milbury suggests hockey take a look at the level of violence, and how opposed the rest of the panelists were against it. Fighting seems to be endemic to hockey, but I heard once that hockey didn’t become a violent sport until it migrated south to areas where people couldn’t understand the game, and the league turned to fistfights to attract crowds. Apparently, the strategy worked. Now, can the NFL survive its own success? I wonder.

I think it would be quite interesting to do some data analysis on logged concussions and the frequency and types of fights that hockey players get into. I’d also like to see data on the coincidence of recorded fights and concussion in contact/collision sports athletes. It might shed some light on this, and also help us see other contributing factors, such as behavior choices in everyday life, which can jeopardize the safety and future of student athletes — not because of what injuries they cause, but because of the injuries that they may contribute to.