A recent article reports that aggression is common in individuals with Huntington's disease. Authors report rates of aggressive behaviors between 22% (for clinic patients) and 66% (for hospitalized patients) among individuals with HD. What do they mean by aggression, and how should we interpret these numbers? It is important to remember that aggression (as defined in this article) and violence are NOT the same thing.
However, the most important thing to learn is not how often it occurs, but how we can understand, cope with and treat aggressive behaviors in HD.
The article: Published in the Journal for Huntington's Disease [Fisher CA 2014], authors systematically reviewed all studies that have reported on aggression in HD. When interpreting the high numbers remember:
- The academic aggressive behavior definition; Behavior with intent to harm, threaten, or injure objects or persons. This can be verbal (yelling or swearing), or physical (hitting an object or a person). So a very large range of behaviors (mild and severe) contribute to the high numbers in these aggression studies.
- The patient populations: Not surprisingly, the highest reported rate of aggression in HD (66%) comes from a studies of patients who were hospitalized or institutionalized, the smaller rates reported are those from patients followed in clinic.
In general, studies show that aggressive behaviors tended to occur more frequently in men, in earlier and middle stages of disease (though important to remember that individuals with late stage disease in long term care facilities are rarely included in studies) in those with perseverative (obsessive-compulsive) behaviors and in depression with suicidal behaviors.
In another recent article published in JAMA Neurology [Liljegren M 2015], authors report a 16% criminal behavior rate in their clinic patients with HD. When interpreting this number, it is important to understand that the criminal behavior in HD related mostly to traffic violations where driving under influence of alcohol was most common.
Neither article discussed violent crime and HD. Earlier study suggests that violent crime is rare [Jensen P 1998].
How do we cope with aggressive behaviors in HD? Whatever the definition, it is not easy dealing with aggressive behaviors; and likewise there are no easy answers. However a few suggestions:
Get educated: Knowledge about this and every symptom of HD is important. But knowledge isn't enough. Understanding why the symptom is occurring, and empathy for the person in these situations is essential.
See your doctor: Ask for education about aggression and other symptoms of HD. If the person with HD will not see a doctor, the care-partner still needs to seek assistance from a professional. Aggressive behaviors don't go away, and are likely to escalate without some type of (environmental or other) intervention.
Call 911: If aggressive behaviors threaten the person with HD, or others, calling 911 for emergency services is best action.
For aggression that is not emergent:
Prevention: In most cases, irritability precedes aggression. Identifying and modifying the cause of irritability is the most important way to prevent aggressive behavior. Causes of irritability can include frustrations with no longer being able to perform tasks as previously, physical discomfort including hunger, pain, other medical problems, sleep deprivation, too much noise or other stimulation, etc, or not being able to meet demands of work or home as previously. In earlier disease, both the individual with HD and care-partner can identify and work to both recognize and modify factors that cause irritability. In later stages of disease, the person with HD has difficulty communicating what is causing distress. If you can't figure out what is causing irritability, seek help from your doctor or other HD professional. Support groups often have members who can give good advice on how to identify "triggers" and how to implement behavior modifications. Though there are often trigger patterns, causes of irritability change from day to day and over stages of disease. And try our best, we can't always find a reason.
Treatment: Most important is providing an environment that promotes comfort. Good sleep hygeine is essential. Treating other symptoms of HD, particularly perseverative (obsessive-compulsive or getting stuck) behaviors, anxiety and depression, and irritability, or paranoid thoughts with appropriate medications. An SSRI type of drug like sertraline (Zoloft®) will give benefit to most of the listed symptoms. See your doctor frequently to assess best dosage or the need to add another drug if the SSRI is not sufficient.
Aggression and substance abuse: This is a huge problem. Aggression is hardest (close to impossible) to treat when there is ongoing alcohol or substance abuse. This is true in HD, as in other diseases and in the general population. Violent aggressive behaviors most often occur in the setting of alcohol abuse.
Bottom Line: Get educated, gain understanding and always ask for help. Aggressive behaviors are too hard to handle on your own.
Fisher CA, Sewell K, Brown A, Churchyard A. Aggression in Huntington's disease: a systematic review of rates of aggression and treatment methods. J Huntingtons Dis. 2014;3(4):319-32. doi: 10.3233/JHD-140127. PubMed abstract
Liljegren M, Naasan G, Temlett J, Perry DC, Rankin KP, Merrilees J, Grinberg LT, Seeley WW, Englund E, Miller BL. Criminal behavior in frontotemporal dementia and Alzheimer disease. JAMA Neurol. 2015 Mar;72(3):295-300. doi: 10.1001/jamaneurol.2014.3781. PubMed abstract
Jensen P, Fenger K, Bolwig TG, Sørensen SA. Crime in Huntington's disease: a study of registered offences among patients, relatives, and controls. J Neurol Neurosurg Psychiatry. 1998 Oct;65(4):467-71. PubMed abstract