Ms. Axxx is a 53-year-old woman who sustained a severe traumatic brain injury in a motor vehicle accident in the 1970s, leaving her disabled. She currently lives in a group home. She has been experiencing increasingly frequent and intense episodes of verbal and physical aggression. A neuropsychological evaluation was requested to provide treatment recommendations. The evaluation found that Ms. Axxx has significant cognitive impairments consistent with her traumatic brain injury, including poor memory, difficulty regulating behavior, and emotional lability. Her aggressive outbursts are likely due to frontal lobe dysfunction causing disinhibition syndrome.

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Neuropsychological Evaluation
Patient Name: MVA leads to TBI and CR placement in an aggressive middle-aged woman
Date: X-XX-XX
Identifying Data: Ms. Xxxx is a 53-year-old, white, single woman who sustained a severe
traumatic brain injury (TBI) in a 19XX motor vehicle accident (MVA) which left her severely
disabled. She currently resides in an OMRDD operated group home (IRA) in xxxxx, New
York. She was referred for evaluation by her primary care physician, Dr. K.
Information Sources:
1) Clinical Summary, K, M.D. 1-16-98
2) Psychological Assessment M Ph.D. 7-25-95
3) Neuropsychological Evaluation, H Ph.D. 3-30-92
4) OMRDD Individualized Service Plan, 11-13-97
5) OMRDD Residential Habilitation Plan, 11-13-97
6) OMRDD Psychiatric/Mental health Worksheet,1-29-98
7) Lab Data and CT Scans
8) Psychiatrist reports from the patient’s chart
9) Overt Aggression Scale (OAS), 1-29-98
10) Galveston Orientation Test,1-29-98
11) Group Home staff interview, S, RN, 1-29-98
12) Clinical interview, patient, 1-29-98
Reasonfor Referral: During the past three months, Ms. Axxx has had increasingly frequent and
more intense episodes of verbal and physical aggression. These episodes and other recent
problems have been characterized by staff as follows: “yelling, screaming, swearing, making
derogatory statements about other residents, staff and family…outbursts seem to have no
identifiable precipitants…frustrated over minor situations like trying to put on her
shoes…hoarding items…discovered during the middle of the night emptying of the contents of
her closet and dresser onto her bed…redirection and humor seldom works to change her tone
anymore…more irritable and verbal threats are more common…throws things during these
episodes…in recent months her gait problems have increased and led to numerous falls; As a
consequence, she is now confined to a wheelchair.” This evaluation was requested for treatment
recommendations.
History of Present Illness: In 19XX when Ms. Axxx was 15 years old she sustained a TBI in a
motor vehicle accident (MVA). Following the MVA, she was comatose for 2 months. Her
injuries were described in the chart as follows: “contusion of the brain stem involving the
reticular formation”; “contusion of the right cerebrum associated with left sided spastic
hemiplegia”. “Damage to the left hemisphere, suspected secondary to marked spasticity of the
right arm and leg.” Ms. Axxx was in her freshman year of high school when the accident
occurred. Before the accident, she was “an average student academically, who participated in
all sports and was considered an expert swimmer”.

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Ms. Axxx was discharged home after the accident to live with her parents and sister. By April of
19XX the family concluded “they were unable to meet her needs at home” and Ms. Axxx was
admitted to the XXX Developmental Center. In July of that year, Ms. Axxx was transferred to
the XXX Developmental Center and 10 years later she was placed in family care where she
managed more or less successfully until 19XX when “she had to be moved to a more restrictive
level of care (ICF) (XXXX Group Home in xxxxx) because she was having frequent falls and
emotional outbursts”. Six months later she was transferred to the XXXX Group Home in xxxxx
in order to “be with a more appropriate peer group”.
Longstanding symptoms and problem behaviors have been described as follows: “frequent
outbursts of swearing at and insulting others…overly demanding attitude for attention, smoking
and falling…problems processing new memories…easily frustrated and will yell at peers
showing a total disregard for their feelings (“I don’t belong with these retards; it’s all because
of that stupid accident.”)…gentle and good natured one moment and explodes in a fit of temper
the next…upset by loud noises, being rushed and being reminded that her skills are not what they
use to be…a perfectionist…frustrated if things aren’t just right…unable to stop a task once she
starts it until the task is complete…continues cleaning her face until told to stop…thinks about
what happened 30 or 40 years ago as if they are happening now…wants to relate only to staff
and seems obsessed with cigarettes…difficulty coordinating her movements and her memory is
significantly impaired especially for short-term information.”
Ms. Axxx’s strengths, interests and character traits include the following: “honest…likes
shopping and going to shows…particular about her appearance…important to look nice…values
and protects her possessions…loves to help…happy when she accomplishes her work with
precision…values her family…likes people who will listen and understand…sensitive and
understanding…excellent sense of humor…would like to do everything by herself and not need
help…wants a place to herself…has a private room and redecorated it to make the room
hers…enjoys knitting and listening to 60’s music…does not want to stop smoking.” Family is
very interested in her care and visit often.
CT Scans of Head: 1988 - “cortical atrophy associated with marked dilatation of the entire
ventricular system”. 1995 - “hydrocephalus with dilatation of the lateral, 3rd and 4th ventricles,
old right occipital infarct, no change from 1988 CT scan”
Current Medications: Atenolol 100mg qd at hs, Estrace 0.5mg qd, Provera 2.5mg qd, Accupril
40mg qd, Catapres-TTS #3 patch q 1 week and Calcium Carbonate 650mg bid.
Carbamazepine (Tegretol) 200mg tid since 1993, prescribed by Dr. F., psychiatrist at the County
Mental Health Center, for agitation and aggression. Benefit from Tegretol has been limited.
Prior to 19XX, she took Trilafon for two years without benefit.
Medical History: Significant for hypertension, hydrocephalic dementia, TBI, R/O CVA.
Laboratory Results:11-20-97 CBC without differential-WNL, Carbamazepine level 6.4.

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Current Neuropsychological Test Results:
1. IQ borderline to mild MR
2. Left visual field cut
3. Left auditory dysfunction
4. Poor verbal memory
5. Poor ability to plan, execute, monitor and correct behavior
6. Impoverished ability to learn new material
7. Emotional lability is probably a disinhibition phenomenon
8. Rigid with perseverative qualities
9. No evidence of decline in cognitive functioning
10. Impaired attention, auditory comprehension, recall and recent memory
11. Speech fluent but flat and slow
12. Moderate depression
13. High anxiety
14. Poor self esteem
Mental Status Examination: Ms. Axxx was a moderately obese, wheelchair bound
woman with short but well styled red gray hair, blue eyes, a hirsute, chubby face and a
ruddy complexion which flushed frequently. She wore large stylish glasses and a natty
burgundy and green corduroy outfit. Her eyes were downcast until I asked her to look up
at me. She was pleasant and cooperative and seemed to enjoy the give and take of the
interview. At times her affect was flat and at other times full and appropriate. She told
jokes and enjoyed a hearty laugh. She spoke in short simple sentences. Her speech was
fluent, relevant and coherent but soft and dysarthric. About the Home, she said “not
good; too many bosses; I don’t like people telling me what to do; they won’t let me smoke
cigarettes when I want to.” She doesn’t know what causes her angry outbursts; “usually
it feels like nothing”. Her free time is spent “spoon knitting” cords of yarn which are
later made into afghans and blankets. She enjoys attending the Sheltered Workshop
“because it’s a place to go and something to do and I earn some money”. Her
dissatisfaction could be distilled into this one sentence; “I’m an adult and I don’t want to
be treated like a child”. There were no signs of psychosis or delirium. She was neither
hallucinated nor delusional. She was alert and her sensorium was clear but she was
grossly confused and disoriented. Although she could provide many accurate details of
her childhood, she was oriented only to name and date of birth; she did not know the
time, day of week, month or year and could describe her current location only as “a
doctor’s office somewhere”. Her insight and judgment were severely impaired.
Conclusions: Based upon a review of Ms. Axxx’s history, CT scan findings,
neuropsychological signs, symptoms, test results and problem behaviors, the following
conclusions can be drawn directly and by inference:

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1. Neuropathology: MVAs are the most common cause of TBI. TBI sustained in an
automobile accident usually leads to a characteristic pattern of neuropathological
changes due to the dynamics of an auto accident and the physics of the injury:
1) Diffuse axonal injury, a disruption in the connections between the brain stem
reticular formation and the cortex
2) Because of their vulnerability, cortical contusions involving the temporal and
frontal lobes.
3) There is a rough correlation between length of coma and the severity of TBI.
Ms. Axxx was comatose for two months which suggests severe head injury.
Severe TBI usually causes loss of neurons in the form of diffuse cerebral
atrophy, demunition of white matter and hydrocephalus ex vaccuo (ventricular
enlargement due to loss of cerebral tissue). Hydrocephalic dementia can be
seen in her brain CT scans. She has never been seen by a neurosurgeon for
evaluation of her hydrocephalus.
Ms. Axxx’s injuries are consistent with all of the above.
The right occipital infarct seen on Ms. Axxx’s CT scans may have been caused by the
rupture of capillaries during the accident or by a subsequent stroke. The infarct
caused her left visual field cut. These lesions can also cause alexia, agraphia and
constructional apraxia. Victims of severe TBI are 10 times more likely to develop
progressive, degenerative dementia than the general population.
2. Episodes of Verbal and Physical Aggression: Frontal lobe dysfunction often causes
behavioral and/or emotional disinhibition syndrome. Disinhibition is a disorder of the
expression of emotion not a disorder of emotion. Angry outbursts are sparked by
trivial stimuli and do not reflect extreme feelings of rage. Patients with disinhibition
syndrome are unable to control or modulate the expression of emotion. These
patients often make vulgar or socially inappropriate remarks, show poor judgment
and display rapidly shifting moods and irritability. Damage to the inferior orbital
surface of the frontal lobes can lead to outbursts of rage and violent behavior.
Deficits in self-awareness commonly seen in victims of severe TBI are also
contributing to this problem. The patient shows an inability to: 1) perceive herself as
others perceive her, 2) recognize her internal motivations, 3) critique her own
behavior 4) accurately identify her strengths and limitations. Most patients with
deficits in self-awareness lose the ability to learn from experience, develop a
generally more demanding attitude and exhibit reduced frustration tolerance. Deficits
in self-awareness worsen over time. Denial of deficits in TBI patients is commonly
manifested as anger towards family members because of institutional placement
which the patient believes is unnecessary.
3. Impaired Memory Orientation and Concentration: Impaired Reticular Activating
System functioning seen in diffuse axonal injury leads to unstable levels of arousal,
which in turn causes the following:

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1. Interpersonal relationships are more difficult because the patient tires
easily and cannot follow conversations well.
2. Adjustment to increased stimulation such as noise or confusion is
prolonged and, as a consequence, minor frustrations and loud noises
trigger angry outbursts.
3. Difficulty switching and dividing attention. This is one of the causes of
Ms. Axxx’s behavioral perseveration (“inability to stop a task once she
starts it until the task is complete”; “extended face washing”).
4. Poor concentration and memory.
Fluctuating levels of arousal is probably the explanation for Ms. Axxx’s nocturnal
episodes of “emptying the contents of her closet and dresser onto her bed”.
Temporal lobe damage is responsible for Ms. Axxx’s inability to lay down new
memories and poor auditory comprehension. Damage to the frontal lobes has also
contributed to her memory problems and caused impairment in Executive Functions
(the ability to organize, plan, monitor and correct behavior, carry out purposeful
action and solve problems). Impaired executive functions is another factor causing
Ms. Axxx’s behavioral perseveration and also leads to frustration which acts as a
trigger for her emotional outbursts.
4. Depression: Ms. Axxx is clearly suffering from mild to moderate depression.
Depression is common in TBI patients and caused by “mourning the loss of former
self” and compromised anterior cerebral functioning. Poor self-esteem is evident in
Ms. Axxx’s attempts to differentiate herself from the other residents, perfectionism,
desire “to help” and identification with staff members. She tries to compensate for
poor self-esteem in adaptive ways such as: (1) paying attention to her appearance, (2)
using her intact skills (i.e. knitting), (3) reaching out socially.
5. Medications: Two of Ms. Axxx’s current medications may be contributing to her
cognitive impairment. She takes Atenolol 100mg qd. Atenolol is a beta blocker
which can cause depression and cognitive impairment. Its use is generally avoided in
patients with dementia. Catapres (Clonidine) is an Alpha 2 antagonist and can cause
confusional states. Also, dosing Carbamazepine is tricky: Carbamazepine induces its own
metabolism. Over an 8-week period the half-life declines from about 36 hrs. to between 10 & 20 hrs.
Consequently,the dose must be adjusted upward after the first 8 weeks of treatment, sometimes to
twice the dose arrived at during the first 2 to 3 weeks of treatment. Steady state is reached over a
period of about 4 to 5 - ½ lives. Because Carbamazepine metabolizes itself, this period changes over
time. Assuming a ½ life of 15 hrs., after 8 weeks of treatment, steady state would be achieved every 4
days or so. When increasing the dose after the first 8 weeks of treatment, a level should be obtained
every week until a known effective level is achieved for three consecutive weeks
6. Because Ms. Axxx’s cognitive dysfunction is variable, behavioral approaches should
be tailored to her specific deficits and strengths. A behavioral plan designed for her
would differ from a plan developed for a mentally retarded individual. The plan
should be presented to her as a means of reducing staff control and increasing her

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autonomy. She should be an active participant in its development and she should
agree to its terms. She should be given a copy of the final plan.
Diagnosis:
1) Hydrocephalic dementia
2) Personality change due to traumatic brain injury, disinhibited/aggressive type
(Disinhibition syndrome)
Recommendations:
1. Antipsychotics, anticonvulsants, antidepressants and, during the acute phase of
TBI, beta blockers have all been used successfully in the treatment of agitation
and aggression associated with disinhibition in TBI patients.
Several antidepressants have a direct effect on emotional disinhibition as well as
an antidepressant effect. In descending order, relative to the direct effect on
emotional disinhibition, these drugs are: (1) TCA’s, Nortriptyline and
Desipramine, (2) Trazadone (starting at 25mg qd and increasing by 25mg every 5
days), (3) Sertraline (Zoloft) (starting at 25mg qd titrating to 100mg or more qd).
I suggest Dr. K reconsider her antihypertensive medication regimen. We could
start her on Sertraline (Zoloft) 50mg qd titrating up to 150mg qd for depression
and disinhibition and titrate up her Carbamazepine to a dose where we see a blood
level of 8 for a full 8 weeks. I will speak with Drs. F and K about these
recommendations.
3. In order to improve Ms. Axxx’s self-awareness and reduce denial, provide her with
continuous feedback concerning how her behavior affects others. For example,
audiotape one of her verbal outbursts and at a later time when she is calm play the
tape for her while explaining the impact her behavior had on others. She must
perceive this feedback as non-judgmental.
4. When she expresses anger towards her family about institutional placement, ask her
why she thinks her family placed her in institutional care and have her put her
response in writing, if she can. Review her answer with her and help her to
internalize this new understanding.
5. Explain the mechanism of denial of deficits to the family so they will not respond to
her criticism with guilt and resentment and reduce visitation.
6. Stability and predictability will limit frustration and emotional outbursts. Establish a
predictable and consistent daily routine for Ms. Axxx.
7. Staff should always try to communicate important information using the same
language. Staff might consider creating a list of sentences to use when responding to
Ms. Axxx’s questions.

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8. When Ms. Axxx is agitated, communicate with her using the following techniques:
a. Give one direction or ask one questions at a time.
b. Use short, simple sentences with familiar words.
c. Use no choice directions.
d. Use touch and eye contact to calm her.
e. Announce any physical contact before touching her.
f. Always approach her from the front.
g. When she is agitated, tell her you understand that she is frightened and
frustrated and you wish to help her overcome these feelings.
h. Staff who have the best relationship with Ms. Axxx should be designated to
intervene and help calm her when she is agitated.
i. Develop a consistent plan for intervening when Ms. Axxx becomes agitated
and insure that all staff are aware of the plan.
9. To mediate arousal problems, establishing her baseline arousal cycle by recording
arousal level every 30 minutes each day for one week using a simple numerical rating
system such as: 4 = fully alert, 3 = somewhat somnolent, 2 = tends to drift into sleep
on and off, 1 = barely arousable. Once a pattern has been identified, provide rest
breaks but not naps during the periods of greatest fatigue. Schedule the most
enjoyable activities for periods when Ms. Axxx is not at peak arousal but slightly
fatigued. The task will act as a reward or incentive to persist when tired. Schedule
the most demanding activities after a period of sleep. Do not schedule hours of
unbroken activity.
10. To improve awareness of deficits, with Ms. Axxx’s participation, create a list of her
most serious deficits, their impact on her daily life and methods she can use to
compensate for each deficit. Review this list frequently. Again, this must be non-
judgmental and presented with a positive slant.
11. To limit perseveration, pause for several minutes between activities; the next activity
should be completely unrelated to the previous one.
12. Provide Ms. Axxx with tools to compensate for memory deficits:
Teach her to use:
(1) mnemonics
(2) paired associate learning
(3) repetition
(4) help her create a memory log including:
a. autobiographical information
b. facts about the facility
c. information about her brain injury
d. a detailed daily schedule

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e. a calendar with scheduled appointments, activities, etc.
f. things to do list
g. list of important names with identifying information.
(5) Repeat all important information/instructions many times each day.
13. When Ms. Axxx makes a provocative remark, try to be matter of fact in your
response. Avoid any statements which she could perceive judgmental or moralistic.
14. When she becomes verbally aggressive, respond as follows:
a. Do not take her anger and hostility personally.
b. Ignoring the overt content of her remarks and respond to the underlying
feeling: “Your anger is probably caused by your frustration about not being
able to do things for yourself.”
c. She responds to humor. Try to defuse a tense situation with humor.
15. A special relationship with one staff member would go a long way towards improving
Ms. Axxx’s self-esteem.
16. Staff should emphasize Ms. Axxx’s achievements, skills and interests in frequent,
brief contacts to subtly bolster her self-esteem.
17. Try to identify events and interactions which seem to improve her mood and weave
more of them into her daily routine.
18. At all times, treat Ms. Axxx with respect and as a responsible adult. She is highly
sensitive about this subject. Given the overall context, I would allow her to make her
own decisions about the extent of her smoking.
19. Encourage as much autonomy, independence and self-reliance as possible. Comment
frequently on Ms. Axxx’s ability to care for herself.
20. Engage her in as many self-esteem enhancing activities as possible.
21. Staff should avoid appearing directive with Ms. Axxx. She will see this as a threat to
her self-esteem and become oppositional as a means of asserting her autonomy.
22. Mental tasks beyond Ms. Axxx’s capacity may produce frustration and aggression.
Although this does not mean that new things should not be tried, be sensitive to her
response to new tasks and backtrack if necessary (maybe try again later). Avoid
confronting her with tasks which stress her areas of weakness.
23. Ask family members to visit at regular and predictable intervals.

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24. It may be possible to teach Ms. Axxx to use visual imagery to control emotional
disinhibition. When she feels she’s about to explode into a rage, she should visualize
a situation which has the opposite affective content (i.e. a happy family occasion or
an amusing anecdote).
25. Engage her in simple failure free activities.
26. Contacts with staff should be frequent and include the following:
a. Opportunities to vent anger and grief.
b. Assistance with grooming and other activities which will enhance and
maintain her self-respect and self-esteem.
c. Encouragement of autonomy by respectfully placing responsibility for the
outcome of her care in her hands.
d. Assistance with orientation.
27. Staff, other residents and family members should be made aware of the fact that Ms.
Axxx’s emotional outbursts are manifestations of disinhibition syndrome caused by
cerebral impairment. They are involuntary. The thoughts and feelings she expresses
are not genuine.
28. Don’t ask for or expect Ms. Axxx to explain her feelings when she is upset. Simply
allow her to discharge her feelings verbally.
29. Avoid ambiguity, and do not present her with unnecessary choices or decisions. Use
statements such as “Now it is time to take a shower”.
30. Ms. xxx enjoys the attention of others, particularly those in positions of authority (i.e.
staff). Staff should reinforce her positive behaviors with attention, and to the extent
possible, extinguish negative behaviors by withholding attention.
31. Attempt to set limits on Ms. Axxx’s behavior without limiting her ability to express
feelings. For example, when she is angry with another resident, tell her it is okay to
have these feelings while simultaneously indicating that confronting another resident
in an aggressive way is not acceptable and probably does not reflect her true feelings.
32. Limit confusion and confusing stimulation. Family visits may be overwhelming at
times and some recreational activities may not be well tolerated

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33. An effective behavior management plan must begin with a system of tracking which
can shed light on the following:
a) Antecedent
What happened before the behavior occurred, what triggered or
precipitated the behavior. Antecedents can be internal (i.e. frustration or
anxiety) or external (i.e. conflict with roommate or interaction with staff.)
b) Behavior
What need is the patient attempting to satisfy through the behavior or
what goal is the patient trying to reach through the behavior.
c) Consequences
Did the behavior result in the satisfaction of a need or was a goal met.
Were the consequences reinforcing or non-reinforcing.
An outline of the tracking process is attached.
34. She has hydrocephalus; my wish to have her evaluated for placement of a VP shunt
by a neurosurgeon.
_________________________________
Drew Chenelly, Psy.D. Date:
Clinical Neuropsychologist