|
News & Views - Jun, 2000 Issue #70
|
Explosive Behavior
Research on Neurological Predisposition
Summarized By Loi Eberle, M.A.
from published work by
F. LaMarr Heyrend, MD, Intermountain Hospital
800-321-5984 and
Donald Bars, Ph.D.,Behavioral Management Centers 800-640-2518
[F. LaMarr Heyrend, M.D., currently serves as Medical Director
of the Residential treatment Center at CPC Intermountain Hospital of Boise, where he also served as Chief of Staff and Board Member.
Dr. Heyrend is directing several on-going research projects, most notably on episodic dyscontrol syndrome, ADD and ADHD, explosive
adolescents, alcohol’s effect on the Auditory EP and the neurophysiology of learning disabilities.
Donald Bars, PhD., was the Director of Treasure Valley Neuroscience
Center, and currently is the Director of Research, Development and Technology for Behavioral Management Centers in Boise, Idaho. He
has worked in the psychiatric field for over 15 years, and has used EEG and evoked potentials technology for over 10 years. Having
started with Dr. Heyrend as an EEG technician, Dr. Bar’s practical experience and detailed analysis of the data gathered during testing
led to the development of patented paradigms. Dr. Bars is a recognized world expert in neurophysiology in relation to behavior and
education.]
The last decade has shown huge advances in the computer imaging technology
used to monitor and analyze the electrical activity of the brain. This technique has almost limitless potential clinical applications.
Currently it is being used to study and treat a multiple range of disorders, from alcoholism and dyslexia, to multiple sclerosis and
depression.
Research conducted by Doctors Heyrend and Bars through the Treasure Valley
NeuroScience Center, one of the leading clinical EEG and EP laboratories in the United States, has involved conducting more than 4,000
EEG studies on children and adolescents. Their studies have shown that many times there is an organic, or neurological basis for explosive,
out-of-control behavior. They have analyzed brain electrical activity using a series of evoked potential (EP) and quantitative electroencephalograms
(QEEG), which provide a visual display of brain wave activity in response to both visual and auditory stimuli. Their results are exciting
because they have found that a subset of people with the difficult and destructive behavior of explosive, verbal and physical outbursts,
show a significant incidence of a particular type of brain wave activity.
The importance of identifying individuals with explosive and aggressive tendencies
is becoming all too often documented, simply as a result of watching the evening news. Equally important is the need to develop methods
to help these individuals interact effectively in the world around them.
Children who have explosive, uncontrollable outbursts, brought on by minor
or seemingly insignificant environmental stimuli, not only are difficult to diagnose and treat, but may also be predisposed to much
more serious behaviors in their adulthood. Over thirty years ago Stevens et al tried to alert the psychiatric community to the importance
of identifying this population, when they wrote:
“The high incidence of this behavior disorder … during elementary school
years and the evidence that such disorders may be precursors of adult sociopathy and psychopathology require critical evaluation of
present diagnostic and therapeutic methods…”
While Dr. Heyrend and Bars’ analysis of the literature in this area acknowledges
the impact of social factors, they also document evidence of a biological basis for many of these behaviors. Their own research confirms
that neurological deficits are more common in the repeatedly aggressive, violent individual than in the normal population. Their work
“strongly suggests that many individuals exhibiting explosive behaviors have an organic predisposition for violent or explosive behavior
which is an innate characteristic of their central nervous system.”3 Sometimes these explosive behavioral outbursts are
called “neurobehavioral”4 due to be belief that their underlying cause is due to abnormalities in brain function. Heyrend
and Bars caution that if these biological factors are not identified and addressed appropriately, it becomes extremely difficult to
obtain positive treatment outcomes.
Heyrend & Bars differentiate between people who have what they call “episodic
dyscontrol” and those who show the cold, calculated violence of predatory aggression. People with episodic dyscontrol also differ
from those who are showing rational anger evoked by frustration. Too often episodic dyscontrol behavior is simply written off as having
a bad day, which can result in tragedy, “especially in the context of intrafamiliar violence.”5
Assessment
Fields and Sweet6 suggest that “55-75% of individuals who commit
murder without motive or provocation had EEG abnormalities in the absence of observable seizures.” Heyrend and Bars also found significant
electrophysiological differences in a subset of individuals with explosive behavior. These individuals showed a significantly higher
amplitude of a particular pattern/reversal visual evoked potential wave form (the P100 brain wave), when tested. Furthermore, Heyrend
and Bars’ clinical observations suggest that the amplitude of the P100 waveform can reliably predict who will exhibit explosive, uncontrollable
behavior in the future. The suggestion that this brain wave pattern could be used to predict behavior is based on their observations
of young patients who had no history of explosive behavior, but who displayed high amplitudes of the P100 brain wave. When they were
tracked over several years, typically they became explosive by the next maturational stage of brain development or puberty.
Recognizing the neurological markers for explosive behavior and their ability
to predict this behavior in the future makes it easier to find appropriate treatment strategies. When this brainwave pattern is identified,
it not only allows for better intervention, it can also alleviate some of the blame that is frequently directed towards the parents.
In addition to the individuals with high P100 wave form amplitudes who show
explosive behaviors, there is also a subset of individuals with explosive behaviors who have low amplitude P100 wave forms. Heyrend
and Bars suggest that in this case the behaviors are caused by irregularities in the temporal lobe, and that this finding is consistent
with the literature that indicates several kinds of neurological abnormalities can lead to explosive, aggressive, behaviors. Presently
Heyrend and Bars are researching and delineating other groups of organically driven explosive behaviors.
They emphasize the importance of measuring the amplitude of the P100 wave
form, stating: “While not all explosive individuals have this marker, our study suggests that if a high P100 wave form was present,
so were explosive behaviors.” They consider these markers to clearly diagnose a distinct population who needs psychiatric care much
in the same way that a blood test can be used to determine that a person is anemic and needs medical intervention.
Treatment
Individuals with histories of repetitive violent assaults or self-abuse have
been shown to be unresponsive to prior acute psychiatric care7 ,8 ,9 . What seems to be more effective is to identify and
understand the nature of the organic factors that underlie the psychiatric disorder. Then a focused, comprehensive treatment tailored
to the individual’s special needs can be designed, which is necessary because traditional psychiatric interventions have been failures,
many times more than once.
It is felt that the brain regulates aggression through a hierarchical system
of neuronal control involving the hypothalamus, the amygdaloid complex, and the orbitofrontal cortex.10 Some individuals
have temporal lobe problems, while others show a dysfunction primarily in the frontal lobe. There are different pharmacological and
treatment considerations for each type of aberrant electrical activity produced by the brain.
Using computer imaging techniques to show varying brain wave patterns can
help determine which part of the brain may have abnormal functioning:
Frontal lobe impairment, the most common disorder seen, involves
impulsive behavior, where consequences are not considered, and there is little ability to plan or delay gratification, sometimes with
temper tantrums that can become dangerous.
Disorders of the temporal lobes, another common disorder, can turn
normal anger into rage, sadness into suicidal depression, or anxiety into panic. Electrical disturbances in these lobes can create
atypical psychotic symptoms, causing inappropriate sexual behavior, unusual fears and memory problems. They become unpredictable and
exhibit depressed or explosive behaviors without provocation.
Left hemisphere dysfunction results in poor verbal skills and developmental
language disorders. Difficulties in expressing emotions verbally may cause aggression; the success of psychotherapy may depend on
the severity of language and verbal memory disorders.
Right hemisphere dysfunctions can cause social handicaps, even when
there are normal language skills, since there may be problems interpreting body language, facial expressions, gestures, and voice
inflection. Visual processing difficulties can lead to problems in mathematics and science. People with Non-Verbal Learning Disorders
may have normal or above average IQ’s but exhibit socially inappropriate behaviors and need a neuropsychiatric treatment approach
to improve these skills.
Verbal psychotherapy is usually not effective with people with these neuropsychiatric
disorders. This may be due to the great difficulty they usually have in generalizing from an office setting to the home, school or
neighborhood. Since traditional psychiatric treatment programs depend on insight oriented, office based, verbal psychotherapy, this
could be the reason it is usually not effective with people with these disorders, who learn by doing, not by talking. They need therapeutic
experiences “out- in-the-real-world” that provide experientially-based, action- oriented approaches to therapy, such as is found in
outdoor challenge courses. They respond to non-traditional therapeutic approaches such as orienteering, cooperation, negotiation,
expression of feelings, and teamwork, with much less emphasis on verbal skills.
Typically, people who have explosive behavior have normal to above average
IQ scores, frequently showing a pattern of low verbal and high performance. Extremely impulsive with frequent instances of poor judgement,
they exhibit inconsistencies in social, educational, and behavioral functioning. These individuals are not really able to control
their behaviors and will reject adults who do not believe them. Once they are properly identified, then interventions and accountability
can become a treatment focus.
Those lacking in verbal, analytical, or abstraction skills with a short attention
span respond to alternatives to traditional treatment such as age appropriate play therapy, art, recreational and occupational therapies,
and therapeutic horseback riding. Therapy may be conducted while taking walks, or during demanding activities on the ROPES course.
Heyrend and Bars also point out that whether the aggressive behavior is biologically
based or not, it may have a psychodynamic trigger, which when it occurs, the family may unknowingly reinforce the aggressor by rewarding
the behavior. Those rewards must be removed so that the aggression does not provide secondary gains. At that point in therapy, work
can begin to focus on the psychodynamic cause.
Treatments can be adjusted to meet special needs. For example, in order to
reach individuals with attention deficits, substance abuse groups may be combined with occupational or art therapy techniques in a
conjoint group therapy with the psychotherapist. Adolescents who experience difficult tolerating the stimulation or duration of traditional
psychiatric or substance abuse treatment strategies respond better to game-like formats.
Non-traditional methods are used with people with neuropsychiatric complications
in a milieu designed to prevent overstimulation. Slower placed, quiet and sensitive, it is positive in orientation, stressing redirection
without confrontation. Communication and socialization skills are taught using a more predictable behavioral milieu with a clear routine
with behavioral contracting. The educational component is designed for the learning disabled, distractable, and oppositional youth,
using small classes with individualized and self-paced instruction. Psychotherapies are less insight-oriented, using action-based
techniques that elicit non-verbal expressiveness. Groups are smaller, sessions are shorter in duration, and less demanding of cognitive
or verbal skills.
Whenever possible, a combination of approaches should be used: psychotherapy
when there is a good outlook for a cure of the specific psychological disorder, skill-based therapies to decrease disabling symptoms,
and a therapeutic community for psychosocial benefits. An example of combining the therapies would be a level system that allows for
specific privileges to be obtained through behavior contracts, individual therapies, and token economies.
Therapeutically, according to Heyrend and Bars, people with explosive behavior
appear to have a favorable response to various combinations of anticonvulsant, antidepressant, antipsychotic, and stimulant medications,
with anticonvulsants delivering the most consistent benefits.11 Since it involves problems in emotional expression or control,
it has been suggested12 that this behavior is due to defects in the limbic system function. Heyrend and Bars suggest the positive
effect of anticonvulsants may be because anticonvulsants are thought to exert their effects via the GABAergic systems, whose receptors
are located in the amygdala, a critical component of the limbic system.
Information gained through visual and auditory evoked potentials (EP) and
quantitative electroencephalography (QEEG), gives insight about how physiological factors might be interfering with successful treatment
outcomes. By integrating the results of computer imaging technology with evaluations from other disciplines, it is possible to complete
a multidisciplinary evaluation and treatment strategy that provides, perhaps for the first time, a more genuine understanding of the
“whole” person.
[The information for
this overview was complied from materials produced by the Treasure Valley Psychiatric Center, “Intermittent Explosive Children from
the Medical Perspective,” A Paper presented at the 41st Annual Meeting of the American Association Of Children’s Residential Centers,
“Pattern reversal visual evoked potentials and explosive behaviors,” in Recent Advances in Human Neurophysiology, I. Hashimoto and
R. Kakigi, edtrs., and phone interviews with Dr. Bars]
1 “50% of the explosive patients in our study produce a P100 wave
form of 9.0uV or greater and 97% of the patients with an amplitude in excess of 11 uV are explosive.”
2 Stevens JR, Sachdev K. Milstein V. Behavior disorders of childhood
and the electroencephalogram. Arch Neurol 1968; 18:160-177.
3 Heyrend, F.L, Bars, D.R., Simpson, C.D, Munger, J.D. Nelson, Z.
and Burns, J. Pattern reversal visual evoked potentials and explosive behaviors. Recent Advances in Human Neurophysiology: (1998)
Elsevier Science.
4 Mathews, Williamson, Seals, and Fisher (1993, Jan.) Treatment
planning for violent juveniles. Paper presented at the National. Assoc. of Private Psychiatric Hospitals, 60th Annual Meeting. Fort
Lauderdale, FL.
5 Elliott FZ. Neuroanatomy and neurology of aggression. Psychiat
Ann 1987; 17(6): 385-388.
6 Fields W.S, Sweet, W.H. (eds). Neural basis of violence and aggression.
St. Louis, MO: Warren H. Green.
7 Mathews, D. et al. Treatment planning for violent juveniles, op
cit.
8 Zoccolillo and Rogers (1991). Characteristics and outcome
of hospitalized adolescent girls with conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 30(6),
973-981.
9 Gabel and Shindledecker (1991). Aggressive behavior in youth:
Characteristics, outcome, and psychiatric diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry, 30(6), 982-988.
10 Bear, D.M. (1991) Neurological perspectives on aggressive behavior.
Journal of Neuropsychiatry, 3 (2),S3-S8.
11 Donovan et al, Divalproex treatment of disruptive adolescent:
A report of 10 cases. j Clin Psychiat,58(1),12-15.
12 Mathews et al. Treatment planning for violent juveniles. op cit.
13 Tancredi, LR, Volkow B. Neural substrates of violent behavior:
implications for law and public policy. Int. J Law Psychiat 1988; 11:13-49.
14 Maletsky BM. Treatable violence. Med Times, 1972; 100(10):74-79.
15 Tancredi, LR, Volkow N. op cit.
Copyright © 2000, Woodbury Reports, Inc. (This article may be reproduced
without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)
|