Unit 2 Written Assignment
CASE REPORT
PSYCHIATRY & BEHAVIORAL SCIENCES
Kristy S. Lane,1 B.A.; Maria E. St. Pierre,2 M.A.; Margo D. Lauterbach,1 M.D.; and Vassilis E. Koliatsos,1 M.D.
Patient Profiles of Criminal Behavior in the Context of Traumatic Brain Injury*
ABSTRACT: Traumatic brain injury (TBI) can lead to significant post-traumatic disturbances in mood and behavior, with the frontal lobes playing a key role in emotional and behavioral regulation. Injury to the frontal lobe can result in disinhibition and aggression which can result in police intervention and/or incarceration. We highlight four adult cases with a history of severe TBI with frontal lobe injuries and the pres- ence of post-TBI criminal behaviors. There is evidence to support an anatomical basis for aggressive behaviors, yet there are other risk factors to be considered. Behaviors must be investigated thoroughly by obtaining adequate pre- and post-TBI psychiatric and psychosocial histories. By having a comprehensive understanding of aggression while appreciating the complex relationship between TBI, aggression, and premorbid risk factors, clinicians can more adequately treat patients with TBI, with the aim of potentially preventing criminal behaviors and recidivism.
KEYWORDS: forensic science, traumatic brain injury, frontal lobe, aggression, risk factors, recidivism, incarceration
Traumatic brain injury (TBI) is a significant public health concern and a leading cause of morbidity and mortality in the United States. TBI is defined as an alteration in brain physiology or anatomy caused by an external force (1). Leading causes of TBI are falls (40.5%), motor vehicle collisions (14.3%), struck by/ against (15.5%), assault (10.7%), and unknown/other (19%) (2). Severity of TBI can be determined, among else, with the Glas- gow Coma Scale (GCS), a 15-point scale measuring best motor, verbal, and eye-opening responses immediately after TBI. GCS scores are 13–15 for mild TBI, 9–12 for moderate, and 8 or below for severe. Clinicians may also utilize the Glasgow Out- come Scale (GOS) to measure recovery. Prognosis can vary based on key generic TBI variables (severity, type, and location of injury) as well as individual social, psychological, and general medical variables (prior psychiatric diagnoses, personality traits, available support systems, and physical limitations.) Aggression, acute or chronic, is a major complication of TBI.
There is no concrete definition of aggression in TBI research. One study’s definition of aggression is “verbal outbursts, physi- cal violence toward objects, physical violence toward persons, and self-directed violence” (3). The reported frequency of aggressive behaviors post-TBI ranges widely from 11% to 96%, suggesting a need for a concise definition of aggression (4). The frontal lobe is involved in the suppression of aggressive
tendencies. Injury to the frontal lobe can cause impulsivity and
an inability to modify behavior, which can predispose one to aggressive and/or violent outbursts (5). Frontal dysfunction may also cause cognitive impairments in attention, memory, and plan- ning. Individuals with frontal lobe injuries may also experience changes in personality, lack of awareness of deficits from injury (anosognosia), and anxiety or depression (6). For the purpose of this report, we have adopted the definition of “aggression” as verbal outbursts and physical violence toward objects and others. In one study, authors recorded aggressive behaviors of 89
patients with a history of TBI and found an increased frequency of post-traumatic aggression among 33.7% of patients with TBI during the first 6 months after the trauma occurred (4). Individu- als with frontal lobe lesions had higher incidence of aggression as measured by the Overt Aggression Scale (OAS). In a recent longitudinal study, 35 of 135 participants (26%) were found to be aggressive between 6 and 60 months post-TBI (7). Another study observed that verbal aggression was the most prevalent form of aggression; other subtypes included physical aggression against objects, self, and others. Among 67 first-time TBI patients, 28.4% reported verbal aggression, with the most com- mon symptoms being angry shouts and vicious cursing with moderate threats of violence (8). Aggressive behaviors cause serious social and often legal con-
sequences for the aggressor. Approximately two million people are currently detained in U.S. prisons and jails. Various studies have reported a wide range (25–87%) of inmates having a his- tory of TBI, compared to 8.5% in the general population (2). In a recent meta-analysis, the frequency of individuals who have sustained a TBI among the incarcerated population is signifi- cantly higher versus the general population (9). One study found that in an Australian prison system, 82% of inmates self-reported a history of at least one TBI, while 43% self-reported a history of four or more TBIs (10). In a similar study, authors found that 86% of 118 male prisoners reported sustaining at least one TBI in their lifetime (11). In a death row sample of 16 inmates, TBI
1The Neuropsychiatry Program at Sheppard Pratt, Sheppard Pratt Health System, 6501 North Charles Street, PO Box 6815, Baltimore, MD 21285- 6815.
2Towson University, Department of Psychology, 8000 York Rd., Towson, MD 21204.
*Funding provided by the Leonard and Helen R. Stulman Charitable Foundation and Women’s Hospital Foundation, Inc.
Received 13 Jan. 2016; and in revised form 15 June 2016; accepted 26 June 2016.
545© 2016 American Academy of Forensic Sciences
J Forensic Sci, March 2017, Vol. 62, No. 2 doi: 10.1111/1556-4029.13289
Available online at: onlinelibrary.wiley.com
was documented in 12 of the cases and seven of the 12 suffered multiple TBIs (12). These findings suggest a possible association between TBI and criminal behavior. Here, we highlight four patients who have a history of severe TBI with frontal lobe dam- age and subsequent aggressive behaviors leading to police inter- vention and/or incarceration. Furthermore, their personal risk factors related to their psychosocial history are considered.
Methods
Researchers conducted a retrospective chart review of patients currently or previously enrolled in the Neuropsychiatry Program at Sheppard Pratt. Cases were selected based on age (≥18 years), history of severe TBI, the presence of frontal lobe injury, and evidence of post-TBI criminal and/or aggressive behavior, result- ing in police intervention or incarceration. For the four patients we chose meeting criteria, we reviewed relevant medical and psychiatric histories and all pertinent legal information.
Case Series
Case 1 is a 37-year-old male with a history of nonpenetrating TBI from a motor vehicle accident at age 22. The patient had an initial GCS of 5 and length of coma >2 weeks. He had multiple brain contusions, including contusions in the left frontal lobe and an epidural hematoma in the left temporo-parietal lobes. He was diagnosed with personality change due to TBI with chronic aggression with assaultiveness and impulsivity; cognitive disor- der NOS with nonfluent expressive aphasia; and adjustment dis- order with depressed mood. There was polysubstance abuse with cocaine, alcohol, and cannabis prior to TBI. After TBI, his violent behaviors toward family members
resulted in multiple emergency petitions and inpatient psychiatric hospitalizations. Violent behaviors included assaults with and without weapons and fire setting. The patient also exhibited sex- ual behaviors in multiple public places. The patient was arrested prior to TBI on drug-related charges; following TBI, he has been incarcerated three times due to assault charges and a parole vio- lation. Case 2 is a 37-year-old male with history of nonpenetrating
TBI from a motor vehicle accident at age 20. The patient had an initial GCS of 4 and length of coma >3 months. He had bilateral dorsomedial frontal and prefrontal contusions (left > right) and diffuse atrophy of the corpus callosum. He was diagnosed with personality change due to TBI with rigidity and oppositionalism, chronic aggression with assaultiveness, impulsivity, and demen- tia. There was a history of attention-deficit hyperactivity disorder prior to the TBI. He had a complex and strained upbringing due to severe marital disputes between his two parents. The father is now his sole caretaker. Since the patient’s injury, there have been multiple reports of
verbal and physical aggression toward his father and staff mem- bers at his residential facility. On one occasion, the patient kicked a pregnant female staff member in the abdomen after an altercation regarding his medication. His aggressive behaviors have led to emergency petitions and inpatient hospitalization. Records describe the patient as someone with an enormous potential for danger related to his aggressive tendencies. Incident reports from the residential facility indicate multiple police inter- ventions following verbal and physical aggression directed toward staff and peers. Case 3 is a 22-year-old male with history of two nonpenetrating
TBIs, both at age 20. The first TBI event was from a motor vehicle
accident while the patient was under the influence of alcohol and possibly cannabis. The patient was in coma for roughly 4 weeks. Neuroimaging revealed bilateral temporal and frontal contusions involving the orbitofrontal cortex. The patient suffered a second TBI event caused by a fall while in rehabilitation one month after his first TBI. Imaging performed after the second TBI event showed left-sided atrophy, small hemorrhagic contusions in the right superior parietal cortex, and a right parietal lobe subdural hematoma, resulting in craniotomy. He was diagnosed with cogni- tive disorder not otherwise specified (NOS) and personality change due to TBI with aggression and global regression. The patient’s mother relayed that the patient was aggressive prior to his injury, however aggression intensified after TBI. Following the injuries, multiple hospital and residential inci-
dent reports noted physical assaults and verbal threats toward peers, residential and hospital staff members, and security offi- cers. The patient has also been sexually inappropriate toward hospital and residential staff. Reports describe decreased safety awareness and labile mood; he is considered a significant risk for aggressive behaviors and assault. His aggressive and violent episodes have required multiple inpatient psychiatric hospitaliza- tions. In one particular incident, after assaulting staff members he also exhibited physical aggression toward objects by punch- ing out windows and throwing glassware. Police were called to the residential facility during this episode, and he was assaultive toward police officers as well. The patient reportedly showed no remorse after any aggressive episodes. Case 4 is a 35-year-old male with history of two nonpenetrat-
ing TBIs at age 23 and 31 and remote history of right temporal cerebral hemorrhage from unknown etiology at age 25. The first TBI was during an assault, when he was hit on the head with a gun with no loss of consciousness. The second TBI resulted from being pulled down from the top of a bunk bed by a fellow inmate while incarcerated for robbery. Neuroimaging revealed a hemorrhage in the right anterior temporal lobe and injury to the frontal lobes, especially on the left. A SPECT scan showed per- fusion deficits in the left parietal lobe and in the right cerebel- lum. The patient was in a coma after the second TBI event for >2 weeks with a GCS of 3. The patient was diagnosed with per- sonality change due to TBI with antisocial behavior, aggression, and mood lability, and cognitive disorder NOS. The patient was raised in a neighborhood where gang violence and drugs were prevalent. He may have exhibited some antisocial personality traits prior to the first TBI. He also had a history of polysub- stance abuse with PCP, ecstasy, and cannabis prior to TBI; post- TBI, he abused a synthetic cannabinoid compound (spice). Since his TBIs, he has had numerous reports of aggressive inci-
dents, including verbal and physical aggression toward peers and residential staff. He has a history of being discharged from multiple rehabilitation facilities due to assaultive behaviors. The patient has been incarcerated two times, the first as a result of robbery (after his first TBI) and the second after assaulting a residential staff member and attempting to assault a peer (after his second TBI).
Discussion
Each patient in this series showed aggressive tendencies post- TBI that were severe enough to lead to police intervention or incarceration. Frontal lobe injuries were present in all four cases. Aggressive behaviors discussed here are very disruptive in both the social and work environment of these patients and endanger the safety of patients themselves and others. Although every case was featured by factors predisposing to aggression other than
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frontal lobe injury, every one of the patients experienced wors- ening of aggression after TBI.
Risk Factors for Aggression
Every TBI patient is different; thus, it is difficult to predict who will become aggressive after TBI. Individuals with a history of frontal lobe lesions will often exhibit aggressive and violent behavior (5,13). The frontal lobe is one area of the brain respon- sible for inhibiting impulses and suppressing aggression (3,5). The limbic system, especially amygdala, plays a crucial role in relaying signals between prefrontal cortex and the hypothalamus. Damage to the frontal lobe can cause a sudden release of amyg- dala-generated signals that can lead to behaviors that may no longer be controlled. This can result in disinhibition, impulsivity, and inability to adjust behaviors (3,13–15). Relevant to the pre- sent study, damage to the frontal lobes may also lead to inability to assess the consequences of actions (14,15). Specific TBI-related and unrelated risk factors for aggression
post-TBI are injury severity, history of multiple TBI events with loss of consciousness, aggressive traits pre-TBI, history of sub- stance abuse, and comorbid depressive and anxiety disorders (4,15,16).
TBI as a Risk Factor for Incarceration
There is substantial evidence indicating a clear association between traumatic brain injuries involving the frontal lobe and aggressive behaviors which can increase the likelihood of police intervention and/or incarceration (3,4,9,15). In a recent meta-ana- lysis, roughly 51% (2079 cases) of 5049 incarcerated subjects had a history of TBI (9). The authors state that the prevalence of TBI was significantly higher in their incarcerated sample com- pared to that in the general population: In the group of survivors of severe TBI, 7% had some kind of legal involvement in the first year post-TBI and 31% had a legal involvement within 5 years post-injury. Tateno (4) found that patients with frontal lobe lesions had higher aggression scores measured by the OAS. In a sample of 60 subjects in a county jail, those who had suf- fered a TBI in the prior year had significantly greater anger and aggression than those who had not suffered a TBI (17). Risk factors for incarceration are similar to those for sustain-
ing TBI and include low socioeconomic status, low education, male gender, history of substance abuse, psychiatric disorders, and a general propensity to engage in risky behavior (9,13,18). There is a complex relationship between aggression, premor-
bid risk factors for aggression, and TBI. Risk factors discussed in the previous paragraph may lead to TBI, which may then lead to aggression. The same risk factors may lead to aggression, which can then lead to TBI. Aggressive behaviors can predate, be caused by, or be exacerbated by TBI. Taking a detailed his- tory from an incarcerated individual with a history of TBI may be crucial to determine what led to the behaviors and why. Prior psychiatric and psychosocial history is especially important to establish premorbid personality traits (3,19). By having a com- prehensive picture of the individual, clinicians as well as legal and law enforcement professionals will have a better understand- ing of how past history may influence post-TBI behaviors.
Legal Implications
The effects of brain injury on behavior may go unnoticed (20). When aggression leads to police intervention and/or
incarceration, the implication often is that the brain-injured indi- vidual has a personality flaw which leads to criminal behavior. The influence of TBI and pre-TBI history of the individual may be overlooked. Because of such omissions, people may attribute blame onto the individual, rather than understanding that the individual has an injury which can in turn affect his/her behav- ior. Socially undesirable behavior becomes the sole focus instead of how TBI and pre-TBI history influences personality and behaviors. Incarcerating such individuals may hamper the poten- tial for full rehabilitation. It is essential to have experts who are well versed in TBI and
resulting sequelae working in the courtrooms on behalf of the injured individual. Multiple studies suggest that the lay public, and even health professionals who are not TBI experts, have many misconceptions when it comes to brain injury symptoms, expectations, and length of recovery (21–24). As the lay public members are selected to be on the jury panel, it is important for TBI experts to relay their knowledge to jury members to educate the jury on certain complications resulting from TBI and how this may affect and/or explain the injured defendant’s behavior. Education of the lay public is crucial such that the juror can make an informed decision before voting toward the conviction or acquittal of the defendant.
Clinical Implications
Based on the previous discussion, to consider frontal lobe injury as the sole cause for aggression and eventual incarceration post-TBI may be an oversimplification. Whenever an individual has a TBI and subsequently encounters trouble with the law, possible reasons for the behavior must be determined in an indi- vidualized manner. It is very important for those working with brain-injured individuals to gather a detailed patient history in an effort to prevent aggression. Properly recording and assessing aggressive behavior should
be a goal in both hospitals and outpatient settings to determine the causal factors for such episodes. A recent study of over 4000 aggressive episodes in chronically hospitalized patients has shown that hospital records failed to document 50–75% of episodes (15). A precise and practical definition of aggression is necessary in order to establish guidelines to documenting aggressive behaviors. This can be used to alert caregivers to specific conditions and situations which may lead to aggressive behaviors, and can enable them to formulate actionable plans in hopes of preventing aggression and recidivism. This will also allow future studies of aggression to be compared with each other and synthesized by recognizing causal and precipi- tating factors for aggressive behaviors in brain injured indivi- duals.
Conclusion
The cases presented here illustrate the fact that neuropsychi- atric manifestations of TBI are multifactorial in origin. When considering individuals with TBI who have been charged with various crimes and have been either convicted or acquitted, it is important to acknowledge the complex relationships that exist between brain injury and prior psychiatric and psychosocial fac- tors to prevent recurrence of aggression and maximize rehabilita- tion potential. It is also crucial to continue to educate the general public about TBI and resulting complications in an effort to facilitate fair, informed, and unbiased trials to those who may be in litigation.
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References
1. BIAA. About brain injury; http://www.biausa.org/about-brain-injury.htm (accessed June 26, 2014).
2. CDC. Traumatic brain injury in the United States: fact sheet; http:// www.cdc.gov/traumaticbraininjury/get_the_facts.html (accessed June 26, 2014).
3. Wortzel HS, Arciniegas DB. A forensic neuropsychiatric approach to traumatic brain injury, aggression, and suicide. J Am Acad Psychiatry Law 2013;41(2):274–86.
4. Tateno A, Jorge RE, Robinson RG. Clinical correlates of aggressive behavior after traumatic brain injury. J Neuropsychiatry Clin Neurosci 2003;15(2):155–60.
5. Palijan TZ, Radeljak S, Kovac M, Kovacevic D. Relationship between comorbidity and violence risk assessment in forensic psychiatry – the implications of neuroimaging studies. Psychiatria Danubina 2010;22 (2):253–6.
6. Prigatano GP. Personality disturbances associated with traumatic brain injury. J Consult Clin Psychol 1992;60(3):360–8.
7. Baguley IJ, Cooper J, Felmingham K. Aggressive behavior following traumatic brain injury: how common is common? J Head Trauma Reha- bil 2006;21(1):45–56.
8. Rao V, Rosenberg P, Bertrand M, Salehinia S, Spiro J, Vaishnavi S, et al. Aggression after traumatic brain injury: prevalence and correlates. J Neuropsychiatry Clin Neurosci 2009;21(4):420–9.
9. Farrer TJ, Hedges DW. Prevalence of traumatic brain injury in incarcer- ated groups compared to the general population: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry 2011;35(2):390–4.
10. Schofield PW, Butler TG, Hollis SJ, Smith NE, Lee SJ, Kelso WM. Traumatic brain injury among Australian prisoners: rates, recurrence, and sequelae. Brain Inj 2006;20(5):499–506.
11. Barnfield TV, Leathem JM. Incidence and outcomes of traumatic brain injury and substance abuse in a New Zealand prison population. Brain Inj 1998;12(6):455–66.
12. Freedman D, Hemenway D. Precursors of lethal violence: a death row sample. Soc Sci Medn 2000;50(12):1757–70.
13. Turkstra L, Jones D, Toler HL. Brain injury and violent crime. Brain Inj 2003;17(1):39–47.
14. Brower MC, Price BH. Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a critical review. J Neurol Neurosurg Psychiatry 2001;71(6):720–6.
15. Silver J, Yudofsky S, Anderson K. Aggressive disorders. In: Silver J, McAllister T, Yudofsky S, editors. Textbook of traumatic brain injury, 2nd edn. Arlington, VA: American Psychiatric Association Publishing Inc, 2011;225–38.
16. Kim E, Lauterbach EC, Reeve A, Arciniegas DB, Coburn KL, Mendez MF, et al. Neuropsychiatric complications of traumatic brain injury: a critical review of the literature (a report by the ANPA Committee on Research). J Neuropsychiatry Clin Neurosci 2007;19(2):106–27.
17. Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: prevalence, neuropsychological functioning and psychiatric disorders. Brain Inj 2003;17(9):731–41.
18. Koponen S, Taiminen T, Hiekkanen H, Tenovuo O. Axis I and II psy- chiatric disorders in patients with traumatic brain injury: a 12-month fol- low-up study. Brain Inj 2011;25(11):1029–34.
19. Ponsford J. Factors contributing to outcome following traumatic brain injury. NeuroRehabilitation 2013;32(4):803–15.
20. McClure J. The role of causal attributions in public misconceptions about brain injury. Rehabil Psychol 2011;56(2):85–93.
21. Gouvier W, Prestholdt P, Warner M. A survey of common misconcep- tions about head injury and recovery. Arch Clin Neuropsychol 1988;3:331–43.
22. Willer B, Johnson W, Rempel R, Linn R. A note concerning misconcep- tions of the feneral public about brain injury. Arch Clin Neuropsychol 1993;8:461–5.
23. Swift T, Wilson S. Misconceptions about brain injury among the general public and non-expert health professionals: an exploratory study. Brain Inj 2001;15(2):149–65.
24. Chapman R, Hudson J. Belifs about brain injury in Britain. Brain Inj 2010;24(6):797–801.
Additional information and reprint requests: Kristy S. Lane, B.A. Neuropsychiatry Program at Sheppard Pratt Sheppard Pratt Health System 6501 North Charles Street PO Box 6815 Baltimore, MD 21285-6815 E-mail: KLane@sheppardpratt.org
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