TBI Irritability, Aggression & Anger. A New Perspective on Anger and Aggression after TBI. Disclosures 9/13/2018. Grant support:

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1 A New Perspective on Anger and Aggression after TBI Dawn Neumann, PhD, Indiana University/ RHI Flora Hammond, MD, Indiana University/ RHI Angelle Sander, PhD, Baylor/ TIRR Memorial Hermann Susan Perkins, PhD, Indiana University Disclosures Grant support: National Institute on Disability, Independent Living, and Rehabilitation Research, Field Initiated Program (Grant #90IF ) National Institute on Disability, Independent Living, and Rehabilitation Research Switzer Research Fellowships Program Priority (CFDA no F-1) The Indiana Spinal Cord and Brain Injury Research Fund The Indiana University Brain Rehabilitation, Advanced Imaging, and Neuroscience Signature Center Initiative TBI Irritability, Aggression & Anger 29-71% Most common permanent post-bi personality & behavioral issue Range of severity Pervasive Home & relationships Work Social Community May interfere with care May prevent living at home Major burden to family Higher perceived stress Marital stress & quality Irritability Aggression Anger 1

2 Evidence anger & aggression is a problem after BI : Evidence for mechanism(s) & management of TBI anger & aggression Conceptual Model: 4 dimensions of irritability Perceptual -Self-talk sees world -How sees world Physiologic -Self-regulation -Impulse control Irritability Relational -Power dynamics -Interpersonal communication Environment -Time management -Structure -Expectations Davis C, Hirsch M, Hammond F, Cook J : Irritability & TBI: A Community-based Participatory Research Exploration. Brain Injury 2010;24(3):210. Negative attributions 2

3 How angry would you be at someone? Attribution-Emotion Theory Attributions of others behaviors Our emotions Intent, hostility, blame Anger Study 1 Is anger after TBI associated with attributions of intent, hostility, and blame? Demographics & Injury Variables 3

4 Main Outcome Measure 21 Hypothetical Scenarios & Ratings (1-9 Scale) Scenarios: Hypothetical situation negative outcome for the subject. Benign (7), Ambiguous (7), and Hostile (7) Narrative text on computer screen 8 th grade reading level Rating Scale (1-9) Anger Intent Hostility Blame So What? 4

5 Negative Attributions Bias Attributions of hostile, intent, and blame are: Elevated compared to norm Disproportionate to the circumstance (benign or ambiguous). Do some people with TBI have negative attribution bias? Importance In non-tbi populations associated with: Aggressive & violent behavior; domestic violence Criminal behaviors Incarceration TBI example Study 2 AIMS Compare negative attributions in people with and without TBI. (Bias) How much of anger variance do negative attributions explain people with TBI? 5

6 Intent Ratings Hostility Ratings 9/13/2018 Demographics & Injury variables Intent Ratings ES p =.014 *p = p = TBI HC ALL BENIGN AMBIGUOUS HOSTILE Hostility Ratings ES p =.039 p =.016 *p = TBI HC 1 0 ALL BENIGN AMBIGUOUS HOSTILE 6

7 Anger Ratings Blame Ratings 9/13/2018 Blame Ratings 7 6 *p <.001 *p =.004 *p =.004 ES TBI HC ALL BENIGN AMBIGUOUS HOSTILE Anger Ratings 6 p =.011 *p =.005 *p <.001 ES TBI HC 1 0 BENIGN AMBIGUOUS HOSTILE Anger explained by Perceived hostile intent & blame 7

8 Current STudy Specific aims Why? What makes someone prone to negative attribution bias? 1. Replicate negative attribution findings (attributions more severe in TBI than HCs) 2. Determine cognitive and emotional factors associated with attributions of intent and hostility, and the amount of variance explained by these variables. 3. Explore associations of negative attributions with participation and life satisfaction Methods 8

9 participants TBI N=105 HC N=105 -Complicated mild to severe TBI -No other neuro d/o or hx of developmental or psych d/o No hx of neurological, developmental or psych d/o Age and gender matched adults. Attributions Measure 21 Hypothetical Scenarios & Ratings (same as last study) Benign, Ambiguous, & Hostile Attribution & Emotional Response Ratings: Intent Hostility Blame Anger Cognitive variables Verbal fluency: letter (FAS), category (MOANS animal, fruits, vegetables) Color word interference: Stroop Perspective taking: Interpersonal Reactivity Index subscale Social inference: The Awareness of Social Inference Test Emotional Evaluation Test Social inference (minimal context) Social inference (enriched context) 9

10 Emotional variables Trait aggression: Buss Perry Aggression Questionnaire Anxiety (STAI trait anxiety ) Depression (PHQ-9) Alexithymia: Toronto Alexithymia Scale-20 Participation & Satisfaction Participation: (PART-O) Productivity Social Relations Out and About Satisfaction With Life Scale: (SWLS) results 10

11 Participant Demographics (N=210) Variable TBI group HC group P-value (n=105) (n=105) Age [Mean (SD)] (13.5) (15.2) Education level [Mean (SD)] (2.0) 15.01(2.5) Race White 81 (77.1%) 76 (72.4%) Black 19 (18.1%) 23 (21.9%) Asian 2 (1.9%) 2 (1.9%) Other 2 (1.9%) 3 (2.9%) Native American 1 (1%) 1 (1%) Hispanic or Latino 12 (11.4%) 8 (7.6%) Sex (Male) 60 (57.1%) 57 (54.3%) Injury variables Variable TBI group Cause of injury Vehicular 48 (45.7%) Fall 20 (19.1%) Assault 9 (8.6%) Other 28 (26.7%) Post traumatic amnesia [Mean (SD)] 5.49 (2.2) Loss of consciousness < 1 hr 29 (30.9%) >1hr, but <24 hrs 18 (19.2%) 1-6 days 16 (17.0%) 7-13 days 7 (7.5%) days 7 (7.5%) days 3 (3.2%) days 11 (11.7%) >60 days 3 (3.2%) Negative Attribution bias Attributions and anger to Ambiguous Actions p=.0008 p=.0139 p=.0008 p=.0006 Intent Hostility Blame Anger TBI HC 11

12 Significant relations to attributions Intent & Hostility Cognitive: Verbal fluency Stroop Social inference Emotional: Aggression Anxiety Alexithymia Blame Cognitive: Verbal fluency Stroop Perspective taking Social Inference Emotional: Aggression Anxiety Alexithymia Blocked stepwise Regression Models What factors explained participant attributions (ambiguous scenarios only)? Block 1: Demographic & Injury variables Block 2: Cognitive Variables Block 3: Emotional Variables Intent Attributions 2.3% 1.Age, Yrs post-injury, PTA, Gender, Education 9.2% 26.3% 2. + Social inference (E) Social Inference (M), Stroop, Letter & Animal Fluency 3. *Aggression *Depression Anxiety, Alexithymia 38% of total variance 12

13 Hostility Attributions 5% 1. Age, Yrs post-injury, PTA, Gender, Education 15.5% 23.3% 2. *Social inference (E) Social Inference (M), Stroop, Letter & Animal Fluency 3. *Aggression Depression Anxiety, Alexithymia 44% of total variance Blame Attributions.7% 1. Age, Yrs post-injury, PTA, Gender, Education 9.7% 3. *Aggression Depression Anxiety, Alexithymia 16.5% 2. Social inference (E) Social Inference (M), PT, Letter & Animal Fluency, Stroop 26.9% of total variance Association with Life Satisfaction & Participation Variable TBI group Participation SWLS Ambiguous anger (0.64) (0.01) Ambiguous intent (0.17) (0.03) Ambiguous (0.02) (0.02) hostility Ambiguous blame (0.64) (0.01) 13

14 Conclusion People with TBI are prone to NAB. Not everyone with a TBI thinks this way. Cognitive and emotional functioning may impact negative attributions. Intent & hostility ratings: 1. Emotional; 2. Cognitive Blame ratings: 1. Cognitive; 2. Emotional Emotional: Aggression; Cognitive: SI Some (weak) correlation with life satisfaction (all attributions) and participation (hostile). Explore CG impact & perspective. Interpretation of findings and clinical implications Aggression Discussion Which first? Aggression or Negative Attributions? Buss Perry Aggression Questionnaire: Anger Physical & Verbal Aggression Hostility ( friends talk about me behind my back people laugh behind my back ; suspicious of others) Aggression associated with: depression; cognition (ie. verbal memory, visuo-perceptual skills and executive-attention functioning); younger age at injury; alcohol and substance abuse; socioeconomic status; and pre-injury factors such as mood disorders, premorbid aggression, and low IQ. 14

15 Infer others mental states (intent, beliefs); ToM Social Inference Discussion ToM often impaired after TBI Clinical implications Screening Treatment approach 15

16 Results Questions? 16