Irritability and Aggression after Brain Injury

Brain Injury Blog by Flora Hammond, M.D.

May 30, 2012

Irritability and Aggression after Brain Injury

Changes in a survivor’s emotions and anger are stressful for families

Janice is about at the end of her rope. Her husband John suffered a traumatic brain injury (TBI) over a year ago. After a long rehabilitation, it seemed like things might return to a somewhat normal state. John returned to work and, for the most part, appeared to cope with the day to day.

But recently, the smallest irritations are causing John to become a font of emotion and anger. Janice wonders if this is a result of his brain injury. Researchers at the Rehabilitation Hospital of Indiana are aware that a TBI may cause long-lasting changes in behavior, ranging in severity from irritability all the way to physical outbursts. These changes often impact relationships, work performance, social interactions and community life. They add to the other stressors imposed by a TBI. 

Although irritability is a common post-TBI occurrence, there is little known about what it is, what causes it, the impact on individuals and family members’ lives, and more importantly, what treatments are effective.

Research on irritability and aggression after brain injury

Researchers at RHI are answering these questions by working alongside individuals with TBI and their families using a “participatory research” approach. Participatory research uses the expertise of the individuals living with a problem day-in and day-out by allowing these “experts” to help shape the direction of the research and interpret the findings.

With her team of researchers, Dr. Flora Hammond, M.D. has conducted fifty focus groups to learn about the lives of individuals experiencing post TBI irritability. Areas that appear to be important to the occurrence of irritability include our perceptions, mood and behaviors, environment, and relationships. This information will help find out how to better treat irritability.

Drug amantadine being studied for treatment

Irritability and aggression are problems that greatly affect the lives of many people living with traumatic brain injury and their families. There has been little research to help guide physicians on how to best treat these challenging behaviors. Recent studies suggest that the drug amantadine might have a new use in helping people with TBI.

Amantadine is a medication that has been used for decades to treat Parkinson’s disease, prevent viral infections, and promote recovery from coma after brain injury. Dr. Hammond, project director of one of the nation’s 16 TBI Model systems sites, recently completed a 76 person pilot study that found amantadine reduced irritability and aggression in people with brain injuries.

She is currently heading a multicenter trial of amantadine for irritability and aggression in which RHI is participating. Dr. Hammond was also part of the research team that recently reported in the New England Journal of Medicine a positive effect of amantadine on early recovery after brain injury. 

This article was reproduced with permission from Dr. Hammond and was originally published in RHI Research Today in May 2012.

Recommended Reading

Emotions after Brain Injury in Adults and Veterans: Tips and information for families and survivors

By Samantha Backhaus, Ph.D., Janelle Breese Biagioni, Ann Deaton Ph.D., Pamela Law, Ph.D., Taryn Stejskal, Ph.D., Judy Sullivan, B.A.

10 responses to “Irritability and Aggression after Brain Injury”

  1. My name is myra alliston. About a year ago,in january, while taking a walk with friends on our property, i slipped suddenly and fell hard on my back smashing the back ofmy head hard on some ice. I was dazed and staring up at sky and i could not readily understand what my husband and friends were saying to me. I was spinning. They had to help me get up and assist me to walk. I later threw up and felt foggy and fatigued. I went to work the next day but became dizzy and went to emergency. When descibing my symptoms they did decide to do a brain scan and determined that i had a mild to moderate concussion and that i needed to rest my brain completely. As a psychologist,i could not return to work for at least a week. It is now 13 months later and i have become extremely irritable and reactive. I find myself noticing suddenly i have my jaw clamped. Soon after that fall i did slip on ice again and fell on my back and hit my head on a tile in the chicken coop. It was not as hard. I was not dizzy or spinning but i hit my head in exactly the same place. My ER doc had warned me to b very careful of reinjuring my head due to the cumulative effects of PCS. IN november 2018 i received a corticsteroid shot in my elbow and while it did wonders for that, i have become even more irritable and “ragey” and reactive.this is very upsetting to my husband and me. I think i am having long term concussion symptoms and they have be exacerbated by the one corticoid steroid shot i had in my right elbow. Do u think your medication or study could help me?

  2. Dear Cindy,
    There is a free tip card link on our website and I suggest the tip card Positive Interactions after Brain Injury by Thomas Novack.
    Here is the link to make the request –

  3. Cindi says:

    Thank you so much for replying to me. I will lookout for triggers before the outbursts. One thing I know is she does not remember the outbursts in the morning! I have read time outs like 15 minutes might help. By then she might be calmer and the storm so to speak blew over. I appreciate your time and this site.

  4. Dear Cindi,
    I can not give specific advice on your daughter since I do not know her, but I can give you some general information. It is important that you have noted the outbursts occur at the same time in the evening. Many individuals with brain injuries reach a point of cognitive and physical fatigue where they are easily overloaded and more likely to be short tempered, irritable, and even have more extreme outbursts such as you describe. These behaviors are an indication they are overloaded and unable to process all that is going on. It is helpful to identify what occurs before the incident happens – not only what she may be asked to do at these times, but also environmental factors such as the amount of activity, lights, sounds, etc. By changing the environment and decreasing the demands on her and the stimuli in the home, these outbursts may decrease. For example, some triggers for individuals are too much noise, ie. a loud television and too many people talking at the same time. Some survivors find it helpful to have a quiet time in the evening. You are wise not to engage in a struggle or argue with her at these times but instead to discuss what happened later after she has calmed down. We have several helpful resources that I recommend. Barbara Webster’s book Lost and Found would be very helpful – here is the link on our bookstore.

    I also recommend several tip cards on behavior after brain injury by Dr. Thomas Novak and you will find them on this page.

    IF these incidents persist, it would be helpful to have her seen by a therapist or psychologist experienced in brain injury.

  5. Cindi says:

    I have a 30 yr old daughter who was hit as a pedestrian 3 years ago. She has outbursts and yells. This seems to happens in the evening around the same time. Her communication with family members who care for her is not good at the time of outbursts. We have been not responding to her as when we do it just stirs the drama more. Any suggestions would be helpful. Ty

  6. Dear Asha,
    Your daughter’s difficulty with controlling her anger and aggression is a very common among children whose frontal lobes have been injured. I suggest that having an assessment done by a neuropsychologist could be very helpful to determine the effects of her injury upon her behavior. A neuropsychologist is a psychologist with special advanced training in brain functions and the effects of an injury upon learning and behavior. Since she is in school, it would also be helpful to have her evaluated for special education to determine the effects of her injury on her learning.

    You did not mention where you live, but if you search for a brain injury association/alliance in your state, you will find more resources.
    Marilyn Lash

  7. Asha Clay says:

    Hi I have a 9 yr old daughter who was struck by a vehicle going 50 miles per hour. She has a TBI and has multiple issues now. The worst is her irritability and aggression. I already have anxiety due to the fact that I should have taken her to the bus stop that morning. But now I do not know how to handle her aggressive outbursts. I have mentioned this to doctors here and I have yet to get the answers I need. I am told that maybe I did not pay attention to her behavior before the accident. I know my child and I know that this is not her normal behavior. I even told the doctors that I will seek medical help elsewhere for her because I am at my wits end not knowing what to do or say. She gets very angry sometimes and lashes out at her siblings. Has anyone had this issue and what can I do or where can I get the help she needs? I myself have a lot of anxiety. She used to be a very sweet girl and now I am not sure what triggers her anger and who to seek medical help from. I really need someone who is familiar with this type of issue.

  8. William Ansberry says:

    I have a 21 year-old son who has severe TBI from an auto accident on 01-12-2014. As of today, 05-01-2014, he is still in the hospital. Currently he is in a rehabilitation hospital, behavioral floor. He has been at this facility for 5 days. Prior to that he was on the rehab wing of a local hospital. At the local hospital, he exihibited the anger/agitation of Rancho Level 4. He would at times roar at the nurses and utter curse words. He also attempted to head-butt another nurse. Another he bit and left a bruise the size of a softball. (They were all great and took it all as part of the job.) Now at the rehab hospital, he has gotten much angrier and physical. He is on four psychotic drugs and spends a good bit of time in a padded room. Mom is staying with him and offers some comfort. (I am back at home with the rest of the children which is 5 hours away.) My question deals with the anger. Is the increase a sign that he is moving through the Rancho 4 level and improving or is it a sign of backpetalling? I need to know where we could be in the journey. I know this is really not enough information to go on but we really don’t know what to expect. His doctors are good, but the nursing staff leaves something to be desired. They complain to my wife when he assult them.

  9. Pat Walley says:

    I have a 18 yr.old adopted son that has TBI/ABI. TBI from a horrible beating at 18mos. when he came into our home. after my husband passed away his behavior became so bad that we had to place him in a residential school. They did wonders for him and was told to place him in a school where he would be with children like himself and could learn a trade, whichI did, , then in March of 2009 he had to have a tumor removed in the same spot as the injury, the results of that has been horrible, his memory is like 50% but his irritability and agitation is far worse. he breaks things, like windows,and doors, etc. this last time he punched a lady in the face, thank god she didn’t press charges and the school came and picked him up. ( he was on a home visit). the doctor at the school has tried all kinds of meds which after awhile don’t work , he nows has him on”Clozaril” He seems to help but last night he was upset because it was fathers day and he missed him. (went into deep grieving after surgery.) and went crazy, broke several windows, cut his arm and had to be held, after it was over he was in complete remorse. I live in upstate NY and he goes to school in Mass. I am so scared for him as I am 73 years old and If he gets in trouble with the law after he finishes school what will happen to him if something happens to me. sorry this is so long but no other way to say it all.

  10. Janet Cromer says:

    Thank you for this information, Dr. Hammond. Participator research has tremendous potential to find answers to the problems survivors and families care about most. Irritability and agitation can disturb families for years after the brain injury. My husband often found his episodes of severe agitation disorienting and troubling in retrospect. We tried combinations of prevention, behavioral approaches, and medication with mixed results. One consequence was that, after an episode, it took days for me to trust Alan’s predictability again and want to be close to him. That’s a high price to pay.

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