s could highlight the relevance of psychotherapy care.
ions cliniques peut permettre de de´gager l’efficacite´ de prises en charge
Annals of Physical and Rehabilitation Medicine 54 (2011) 259–269temporales bilate´rales et un he´matome extradural temporal gauche. A` j3 une lobectomie temporale droite est re´alise´e. L’e´volution est marque´e par
des troubles du comportement majeurs avec des gestes he´te´roagressifs envers les soignants et la famille. Les troubles deviennent tels qu’il doit eˆtre
maintenu dans sa chambre en dehors des activite´s de re´e´ducation et des visites. Les neuroleptiques a` posologie maximale sont inefficaces. Un
antide´presseur permet une ame´lioration du contact. Plusieurs hospitalisations en psychiatrie, ou` une prise en charge institutionnelle et
psychothe´rapique est mise en place, montrent syste´matiquement une ame´lioration nette des troubles du comportement, une possibilite´ de
participation a` des activite´s de groupe et de de´ambulation libre dans un espace ferme´.
Discussion/Conclusion. – L’agressivite´ peut traduire les le´sions ce´re´brales organiques, un syndrome de´pressif, ainsi que le caracte`re iatroge`ne de
l’environnement. Ce cas clinique appuie le fait que les neuroleptiques, en dehors de leur effet de se´dation, ne sont pas un traitement efficace de
l’agitation apre`s TC. Il permet de mettre en e´vidence combien la prise en charge des troubles du comportement rele`ve surtout de strate´gies autres
que me´dicamenteuses et est a` la frontie`re avec d’autres spe´cialite´s.
# 2011 Elsevier Masson SAS. Tous droits re´serve´s.
Mots cle´s : Traumatisme craˆnien grave ; Agressivite´ ; Comportement ; Psychothe´rapiepsychothe´rapeutiques.
Observation. – Un patient de 24 ans pre´sente en janvier 2005 un TC grave (Glasgow 4/15) avec des le´sions intraparenchymateuses fronto-Introduction. – Dans les cas d’agitation et d’agressivite´ secondaire
traitements me´dicamenteux est discute´. L’analyse qualitative de situatCase report. – In January 2005, this 24-year-old patient sustained severe traumatic brain injury (Glasgow at 4/15), with bilateral frontotemporal
injury and temporal extradural hematoma. On the third day, a temporal lobectomy was performed. The patient’s evolution showed severe
neurobehavioral disorders, with agitation and aggressive behavior towards family members and medical caregivers. Maximum doses of
antipsychotic drugs brought no improvement. Antidepressant medication improved social contact. Several stays in the psychiatric unit, where
institutionalized and psychotherapy care were implemented, showed systematically a real improvement of the behavioral disorders, increased
participation in group activities and the ability to walk around alone in a closed environment.
Discussion/conclusion. – Aggressive behavior can unveil organic brain injuries, depressive syndrome as well as iatrogenic nature of the
environment. This clinical case is based on the fact that antipsychotic drugs, aside from their sedative effect, are not the proper treatment for
agitation following traumatic brain injury. This case also highlights how management of behavioral disorders following TBI should not be based on
pharmacological treatments only but instead should focus on multidisciplinary strategies of care.
# 2011 Elsevier Masson SAS. All rights reserved.
Keywords: Severe traumatic brain injury; Aggressiveness; Behavior; Psychotherapy
Re´sume´
a` un traumatisme craˆnien (TC) grave, le rapport be´ne´fice/risques desIntroduction. – In cases of agitation and aggressive behavior after seve
treatments remains unclear. A qualitative analysis of clinical situationClinical case / Cas clinique
Agressive behavior after traumatic brain injury
Agressivité après traumatisme crânien
V. Saouˆt a,*, G. Gambart a, D. Leguay b, A.-L. Ferrapie a, C. Launay a, I. Richard a
a Service de me´decine physique et de re´adaptation, CRRRF-CHU, rue des Capucins, BP 40329, 49103 Angers cedex 02, France
b Service de psychiatrie, centre hospitalier centre sante´ mentale angevin Ce´same, secteur 4, route Bouchemaine, BP 89, 49137 Les Ponts-de-Ce´ cedex, France
Received 8 December 2010; accepted 12 April 2011
Abstract
re traumatic brain injury (TBI), the benefits/risks ratio of pharmacological* Corresponding author.
E-mail address: vsaout8@gmail.com (V. Saouˆt).
1877-0657/$ – see front matter # 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.rehab.2011.04.003

eha1. English version
1.1. Introduction
Traumatic brain injury (TBI) requires multidisciplinary care
on both medical and social levels. The incidence of TBI is hard
to assess. In United States it is estimated at 500/100,000
inhabitants, with no distinction in severity [5]. Jahouvey et al.
reported the annual incidence of severe TBI due to traffic
accidents at 13.7/100,000 inhabitants [18].
Severe TBI is responsible for chronic cognitive and
behavioral disorders [9,36]. The latter can cause difficulties
for a proper social integration and can sometimes be associated
to mood disorders [2,6]. Behavioral disorders such as
aggressiveness can be at the forefront of the clinical picture.
Eleven to 34% of patients after TBI present with agitation or
aggressive behavior [4,39,41]. These disorders can linger over
time and become chronic [2,1].
There are some medication strategies available, yet the
benefits/risks ratio is hard to assess due to the rare number of
studies with a high level of scientific evidence found in the
literature [41,13,33]. A pharmacological treatment is not the
only alternative: Fayol in his review of the literature [11] listed
the various prevention and non-pharmacological strategies. He
differentiated the various approaches: behavioral, global and
psychotherapeutic (including systemic) [27,42] often inter-
twined in clinical practice. The relevance of a psychological
and cognitive approach has been highlighted [32]. However,
very few data exist on the efficacy of these approaches due to
the difficulty in conducting high quality studies.
The great diversity of existing psychotherapeutic models
and techniques enable psychiatrists to bring a pathopsycholo-
gical clinical response [31], even if the psychiatric nosography
can find limits in the description and classifications of disorders
secondary to TBI [12]. As reported by H. Oppenheim-
Gluckman [31], psychiatry had progressively turned away
from the management of patients after TBI to propose
alternatively for the past twenty years new approaches at the
frontiers of neurology, neuropsychology, physical medicine and
rehabilitation (PM&R) and psychiatry. At the crossroads of all
these specialties we can find the issue of ‘‘behavioral
disorders’’ [31]. In fact this ‘‘dual’’ vision separating the
‘‘soma’’ from the ‘‘psyche’’ would not work in case of
behavioral changes after trauma (both in the physical and
psychological sense) such as TBI affecting the patient and his/
her loved ones.
Taken into account the great methodological difficulty, in
this field, to conduct studies on homogeneous cohorts and
according to the relevance of a qualitative study extended over
several years, we report here the clinical case of a patient with
TBI who had access to a combination of PM&R and psychiatry
care with positive results.
1.2. Clinical case presentation
Mr. X, 24-year-old, the youngest of three children, his sisters
V. Saouˆt et al. / Annals of Physical and R260were at the time of the initial injury 26- and 30-year-oldrespectively. He had no previous relevant history, did not take
any medical treatment. He had been living with his girlfriend
for the past four years and worked as an assembly line worker.
On January 22nd, 2005 he was involved in a traffic accident
responsible for severe TBI; he was driving. The initial Glasgow
score was 4/15, the CT-scan showed bilateral frontotemporal
brain injuries and extradural temporal hematoma on the left
side. The patient had emergency surgery. Postoperative follow-
up showed severe intracranial hypertension (IH), up to
50 mmHg, in spite of medical treatment at maximum dosage.
Brain MRI showed enhanced mass effect with severe diffuse
bilateral lesions and large hemorrhaging hematoma on the right
temporal lobe. At day 3, due to the uncontrollable intracranial
pressure, a lobectomy of the right temporal lobe was performed
by the surgical team. Following surgery IH gave way and the
arousal phase started. The tracheotomy was taken out on April
5th 2005 and the patient was transferred to the PM&R centre on
April 7th 2005.
Upon admission the patient had very few spontaneous
movements; there were no obvious motor impairments. Oral
expression was reduced to screams and grunts. The patient did
not seem to recognize his loved ones. The patient was fed
through a gastrostomy tube.
The evolution validated the lack of motor impairments but
alongside the improvement of motor capacities the cognitive
and behavioral disorders became more obvious. Brain MRI
done on April 22nd 2005 showed dilatations of the ventricles
with right-sided frontotemporal gliosis (Fig. 1). Based on the
hypothesis of hydrocephalus being the potential and curable
cause of this slow arousal we started mid-June 2005 with
repeated spinal taps to drain excessive CSF to no avail. There
was no evidence of pain, spontaneous or provoked. The
gastrostomy tube was taken out in November 2005 returning to
normal feeding without swallowing disorders. Standing and
walking were initiated during the month of August 2005.
However, right from the beginning of the arousal process the
following symptoms appeared: disorganized psychomotor
agitation, screams and aggressive gestures towards the medical
staff, at first during invasive procedures such as injections but
also during nursing care.
At the end of 2005, 12 months after the initial injury, the
patient did not seem to have recovered from posttraumatic
amnesia. There were no motor impairments. The contact with the
patient was quite difficult to establish and needed to be very
progressive. The patient’s oral communication consisted in
incomprehensible words, swears words, or continuous
screaming, sometimes some paraphasias. Oral comprehension
could not be formally tested. Simple orders did seem to be
understood by the patient. The use of daily life objects (fork,
comb) was inadequate and there seemed to be praxis disorders as
well. On a behavioral level, there was a non-directed agitation but
also some ‘‘directed’’ aggressive gesture (towards any type of
nursing care, or due to frustration). There was associated bulimia,
non-selective polyphagia, hyperorality, inappropriate urination/
defecation behaviors and sexual conduct disorders (e.g.
masturbating in public). The patient also developed stereotyped
bilitation Medicine 54 (2011) 259–269motor disorders, prolonged crouch-down position on the bed,