http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2015; 29(1): 118–124 ! 2015 Informa UK Ltd. DOI: 10.3109/02699052.2014.954623

CASE STUDY

Managing aggression in global amnesia following herpes simplex virus encephalitis: The case of E.B. Tracy E. Shannon & Stefanie L. Griffin Lakeview Neurorehabilitation Center, Effingham, New Hampshire

Abstract

Keywords

Aim: This article describes an integrative approach to the case of EB, a 33 year old male who presented with agitation, delusional ideation and global amnesia after contracting herpes simplex virus encephalitis (HSVE) while in a state prison in 2004. Case study: Although several prior case studies have described outcome following acute onset of HSVE, this case presents a unique challenge for rehabilitation in several respects. First, EB’s pre-morbid history is complicated; in contrast with prior HSVE case studies that have typically involved individuals with a relatively high level of pre-morbid functioning, EB presents with limited educational attainment and a prior history of several incarcerations for violent offenses. Post-injury, his presentation includes significant verbal aggression, threats of harm toward others, physical posturing and occasional physical aggression toward his caretakers. Third, EB presents with a fixed delusion that others are constantly taking advantage of him. These features are present in the context of global amnesia and relatively intact cognitive functioning in other domains. Following a brief review of prior HSVE case studies, this study reviews the outcomes of various pharmacological, cognitive, behavioural and integrative interventions designed for management of EB’s aggression and agitation.

Aggression, amnesia, encephalitis, neuropsychological, rehabilitation, traumatic brain injury

Introduction Encephalitis is defined as an ‘inflammatory process of the brain associated with neurologic dysfunction’ (p. 443) [1]. An estimated 20 258 cases of encephalitis are diagnosed each year in the US, with a 5.8% mortality rate [1]. Causes of encephalitis include viruses, small intracellular bacteria and some parasites [2]. Among all viral infections, Herpes simplex 1 virus (HSV-1) is the most common cause of encephalitis, accounting for 10% of all encephalitides [1]. HSV-1 is estimated to be present in 90% of the population, but often remains latent in the trigeminal ganglia until activated (e.g. by infection or facial trauma), at which time it manifests as a labial lesion [3]. Herpes Simplex Virus Encephalitis (HSVE) is believed to be contracted when HSV-1 spreads through the trigeminal nerve to the brain [3]. However, according to the Encephalitis Society, it is unknown how HSV exactly ‘gains access to the brain’ [4]. Neuropathologically, medial temporal lobes, hippocampus and basal forebrain are most commonly impacted in HSVE [3]. Acute onset HSVE results in flu-like symptoms, such as fever and headache. As a result, HSVE is often misdiagnosed early in the process.

Correspondence: Tracy E. Shannon, Hurley Medical Center, Inpatient Rehabilitation, 1 Hurley Plaza, Flint, Michigan, USA. Tel: 614-5796924. Fax: 810-239-1281. E-mail: [email protected]

History Received 6 February 2014 Accepted 11 August 2014 Published online 5 September 2014

Other symptoms include disorientation, hallucinations and dementia. With a mortality rate of 80%, prompt treatment with antiviral medication (e.g. Acylovir) is necessary to prevent the onset of seizure, coma and death. If treated within 2–3 days of onset, with Acyclovir, the mortality rate dropped from 80% to 25% [4]. In the absence of treatment, full neurologic recovery is extremely rare [5]. Advancements in diagnosis and treatment of HSVE have led to decreased mortality; however, morbidity remains high. Long-term consequences of HSVE in a sample of 42 patients include memory impairment (69%), personality and behavioural changes (45%), epilepsy (24%), anosmia (65%) and dysphasia (41%) [6]. Intellectual functions are often relatively preserved [3].

Prior case studies HSVE sequelae are of neuropsychological interest because of the relatively circumscribed nature of injury. Numerous cases have been well-described in the literature, including SS, Boswell, RFR, EP and CW [3] and the case of SZ [7]. Basic perceptual and intellectual capacities have been described as intact in each of these cases. No significant psychiatric or behavioural problems post-HSVE were described in any of the above cases. The case of CW (sometimes referred to in the literature as C or Clive) is of particular interest here because of descriptions of his presentation post-HSVE. Specifically, CW was described as a highly regarded musical scholar who

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developed a dense amnesia after contracting HSVE [8]. CW was described as confabulatory and reportedly developed the fixed belief that he had ‘just woken up’ as a means of explaining what happened to him [9], despite being presented with overwhelming evidence to the contrary. CW’s wife described engaging with CW as ‘cyclic dialogues of obsessive stock questions and stock answers’ and noted that deviation from those cyclical dialogues resulted in a ‘catastrophic reaction’ on CW’s part [9]. To decrease CW’s agitation, clinicians attempted to assist CW in re-learning autobiographical information by providing him with cues, prompts and Socratic questioning daily [10]. This intervention was ultimately abandoned because CW did not demonstrate evidence of learning. Further, he was described as becoming agitated when presented with information that contradicted his belief that he had just woken up. For example, when providers attempted to show CW a video of himself playing the piano, he became upset. Although the above-described cases were noted to have both anterograde and retrograde amnesia at a level that is similar to the individual described in this paper, CW’s agitated response when confronted with evidence contradicting his belief system is most similar to that of this client (EB). More recently, Cavaco et al. [7] described the case of SZ, who, with repeated practice post-HSVE, demonstrated capacity to learn previously unknown songs. SZ is also of interest here because EB demonstrated a similar ability to learn new music lyrics—a capacity that this study attempted to exploit in an attempt to manage his significant behavioural problems, described below.

The case of EB At the time of treatment, EB was a 33 year-old man from New England. He contracted HSVE with subsequent brain haemorrhaging in 2004, while in a state prison. Although he was eventually treated with acyclovir, the haemorrhaging required clot resection, involving removal of tissue from the right hippocampus and amygdala. Sequelae included severe anterograde amnesia, diminished impulse control, agitation and delusional ideation. After surgical intervention in 2004, EB was released from prison and initially lived with family. However, cognitive and behavioural sequelae of his acquired brain injury resulted in significant difficulty with assimilating into the community. EB maintained some awareness of his memory impairment and attempted to compensate for it by leaving himself copious notes. However, similar to CW (described above); EB presented with a fixed belief and became more agitated when that belief was challenged. Specifically, EB believed that other people were trying to take advantage of him by cheating him of his money through exploitation of his memory deficit. As in CW’s case, EB’s belief appeared to represent an attempt to make sense of his reality. In a typical scenario, EB spent money, forgot to write down the amount spent, noticed that the money was gone, became confrontational to those around him and accused others of stealing from him. EB’s large physical frame, premorbid history of violence and constant pre-occupation with the idea that his caretakers or ‘state workers’ were stealing from him combined to make him extremely intimidating.

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EB had repeated psychiatric admissions and was arrested and held in jail on many occasions after 2004, most often for assault, trespassing and harassment. EB began residing in a residential neurorehabilitation setting in June 2009, where the current authors had the opportunity to evaluate and provide intervention to him. Target behaviours for EB included verbal aggression, defined as accusing others of cheating and lying to him, yelling, demanding and threatening to harm/kill others if his needs were not met. These behaviours often lasted for several hours after the precipitating event. During these episodes EB threatened staff and/or demanded to use the phone; if he gained access to the phone, he left threatening messages for all members of his treatment team. Physical aggression, defined as posturing, punching walls/objects and grabbing and shoving staff, was another target behaviour. Short-term treatment goals for EB included decreased frequency of verbal and physical aggression and improved ability to participate in residential and community-based activities. Long-term goals include moving to a less restrictive setting in order to experience improved qualityof-life.

Neuropsychological assessment of EB Neuropsychological assessment was conducted in October 2009. The examiner noted that EB became increasingly agitated after the first 20 minutes of testing, with frequent statements reflecting his belief that the testing ‘has nothing to do with life’. EB ultimately refused to continue testing while in the middle of the WAIS-IV Digit Span sub-test. On the second day of testing, EB again became agitated after 20 minutes, but was able to de-escalate when given a brief break during which he was allowed to interact with a therapeutic dog. EB terminated testing after a subsequent 20-minute testing period. The examiner terminated the evaluation at this point because EB’s limited frustration tolerance resulted in variable performance motivation. Results of testing are presented in the Appendix. Overall, findings demonstrated stronger performance on perceptual reasoning tasks, where EB’s performance was average to high average range. In contrast, his verbal comprehension performance fell in the borderline impaired range. EB demonstrated low average performance on processing speed tasks, while working memory tasks were average. In contrast, memory performances were extremely impaired. Anecdotally, EB appeared to retain material for roughly 30 seconds, although there was some variability. This short retention time could be seen in daily interactions with EB. For example, during a treatment meeting with EB, he became agitated and began screaming and threatening towards his treatment team. EB then punched the table with such force that his hand immediately began to swell. EB left the meeting with a member of the team and within 20 steps of leaving the meeting, EB turned towards the staff member and asked why his hand hurt.

Interventions for management of aggression EB’s cognitive functioning had a significantly adverse impact on his capacity to participate in treatment programmes aimed at helping to improve behavioural control. Specifically, EB

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had difficulty engaging in discussions about his behavioural problems, much less participating in interventions designed to address these problems. EB repeatedly approached providers demanding to be discharged from residential treatment. Discussions about why he was in residential treatment led only to circular discussions in which EB continued to argue using the same language, demanding answers to the same questions, with increased agitation and anger intensity. As a result of his memory impairment, he left interactions feeling as though no one was willing to answer his questions, which perpetuated his belief that others were taking advantage of him. During a 10-month period of data collection related to frequency of verbal aggression, over 850 verbal threats to cause harm to staff were documented; EB engaged in four documented events of physical aggression during that time frame. EB’s relatively unique profile allowed the current authors to study the integrative management of agitation and aggression in the context of an amnestic disorder in an individual with otherwise intact cognition. Although aggression and agitation are not uncommon sequelae of acquired brain injury (ABI) discussion [11], literature on management of aggression combined with an amnesic syndrome after ABI is sparse [12]. Common approaches to managing irritability and aggression in the brain injury (BI) population include pharmacological interventions, psychotherapy (e.g. cognitive behavioural therapy) and behavioural intervention [13]. Pharmacological interventions have demonstrated success when the causes of irritability and aggression are primarily organic. Pharmacological solutions are most effectively employed for acute management of danger posed by an aggressive individual, rather than in long-term behavioural control [13]. While in residential treatment, EB was prescribed Clonidine 0.1 mg tid, Depakote 500 mg bid, Zyprexa 20 mg qd and Trazadone 100 mg qd. Dosage changes were not associated with changes in behavioural problems for EB. While psychotherapy can be employed to address irritability and aggression after BI, modifications are frequently required when working with individuals who have cognitive impairments following BI. Alderman [13] provides a comprehensive discussion of use of common cognitivebehavioural strategies, such as improving self-monitoring and self-appraisal and instruction in coping skills. In EB’s case, global amnesia precluded participation in such interventions because he was incapable of retaining information from moment to moment, much less from session to session. In any case, attempts to engage EB in discussion about his behavioural problems sent him into the perseverative loop described above, in which he invariably became agitated to the point that the discussion needed to be terminated, for the safety of the person with whom he was engaged. It became clear that cognitive behavioural approaches for managing aggression with EB was unlikely to demonstrate benefit, as in the authors’ experience CBT is most efficacious with individuals with relatively good insight, strong language facilities and preserved memory functions. In contrast, behavioural interventions can lead to change in the absence of the need for intact insight, language or memory faculties.

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The structure provided by behavioural interventions can circumvent problems with perception of social and other cues and consequently lead to an increase in conduct that is consistent with rehabilitation aims ([12], p. 673). With this in mind, behavioural interventions appear most likely to be of benefit to an individual such as EB. An outcome of a series of behavioural interventions (i.e. token economy/time out, differential reinforcement of incompatible behaviour and negative response cost) designed to increase pro-social behaviour in an individual with amnesia following HSVE was described [14]. When a token economy/ time out system was employed to address target behaviours including yelling, verbal threatening and physical aggression, verbal aggression escalated, presumably because the individual did not remember why he was placed in time out. In the case of EB, verbal aggression increased after staff members were instructed to evacuate the residence each time he became verbally aggressive. Rather than calming, EB became confused and increasingly agitated because he did not remember being verbally aggressive and could not understand why everyone had left him. The second intervention [14] involved a differential reinforcement of incompatible behaviour (DRI) design. In this intervention, the subject was reinforced for the absence of target behaviours over 30-second intervals. Although some behavioural change was noted (i.e. increased frequency of accessing the reinforcer over the course of 10 weeks), attempts to change the reinforcement schedule from 30 to 60 seconds failed, again because of the subject’s memory impairment. The intervention was terminated because it was not realistic to continue to provide reinforcement on such a frequent schedule. In EB’s case, attempts at reinforcing engagement in treatment (i.e. absence of target behaviour) by providing monetary reinforcers for each activity ultimately proved unsuccessful because EB frequently engaged in threatening behaviour towards staff while demanding a reinforcer. EB was able to ‘recall’ that he should have access to the reinforcer because staff used written documentation to remind him of the intervention and of his success at attending programming activities, but attempts to document his having received the reinforcer were less successful because of his fixed belief that he was being taken advantage of by others. Specifically, when told that he did not ‘earn’ the reinforcer because he had not attended daily programming, EB thought that the staff were lying and taking advantage of his memory deficit. The final intervention [14] employed a negative response cost design. In this intervention, the subject was given a large amount number of tokens and instructed (verbally and in writing) that he would have to ‘pay’ a token for each time he engaged in a target behaviour. At the end of a half hour, if enough tokens remained, he was allowed to trade his tokens for a reinforcer (in this case, cigarettes). This design proved very successful and it was indicated that its success may have been due to the simplicity of the design, which made the contingencies easy for the subject to understand, diminished the memory load on the subject and empowered him to be involved in his own treatment (by handing over tokens when he engaged in target behaviours) [14].

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Although relative success was reported [14] with this approach, EB’s treatment team did not attempt a similar design due to concern for staff safety. Specifically, EB’s 30-second interval of retention and fixed belief that others were taking advantage of him, combined with his physical aggression, raised concerns that asking him to relinquish tokens would result in significant risk of injury to staff. Further, the design of such intervention rests on the assumption that the subject has some insight into his behavioural problems, as well as motivation to decrease the target behaviour. In EB’s case, insight/motivation were absent, as any form of discussion about the nature of his problems or reasons for admission to residential treatment resulted in agitation and activated his perseverative loop.

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antecedents to aggression. Antecedents to aggression typically included any discussion pertaining to finances (e.g. mention of his monthly cheque, treatment groups aimed at teaching budgeting strategies, etc.) and discharge (e.g. EB would ask staff members ‘What do you know about my home life?’ which often led to a discussion about his need for treatment). In addition, loud noises (e.g. other clients in the area yelling), insufficient amount of cigarettes (e.g. when EB was ‘running low’ on cigarettes, he often accused staff members of stealing them or began to ask about his financial situation so he could buy more) and being unable to access the community frequently also served as antecedents to verbal and physical aggression. ‘Relaxation ride’ programme

Behavioural interventions with EB Over the course of a 1-year treatment period, these authors employed a number of behavioural interventions (in addition to those described above) in an effort to reduce target behaviours. Behavioural contracting (i.e. providing access to a preferred reinforcer contingent upon meeting specific behavioural criteria) placed too much demand upon memory. For example, on one occasion when EB lost access to the reinforcer (a preferred outing) because of an episode of aggression, EB was unable to remember having engaged in aggression and, thus, accused staff members of trying to ‘cheat’ him out of an outing. The authors hypothesized that verbal and physical aggression was being reinforced by staff capitulation to EB’s demands. This hypothesis was suggested by evidence of increasing intensity and frequency of aggression over the course of treatment and by anecdotal reports from staff that the only means they knew to extinguish (temporarily) EB’s agitation was to do as he demanded. For example, on one occasion, a staff member was intimidated into taking EB on a ride during a snowstorm, in violation of organizational policy, after EB physically pushed him into the vehicle. The treatment team, thus, designed an intervention to increase staff safety and avoid reinforcing aggression. In this intervention, staff members were instructed to ignore EB when he became verbally/physically threatening and to only respond to him when he was engaging in pro-social behavioor. As expected, an extinction burst occurred (i.e. as EB realized he was being ignored, he engaged in increasingly intense verbal aggression and, ultimately, physical aggression, in order to access staff attention). The intervention was modified such that staff were instructed to evacuate the residence (i.e. remove all staff and clients to safety) when EB became agitated. This intervention was deemed unsuccessful because EB’s agitation only increased further when he found himself alone in the residence. The intensity of aggression was sufficient that the treatment team felt it unsafe to try to continue riding out the extinction burst.

Environmental interventions for EB Following the failure of a number of behavioural interventions, the treatment team explored modifications to the environment that would diminish EB’s exposure to

EB was anecdotally noted to be less agitated when in the community with staff members than when in the residential setting. EB was, thus, offered non-contingent ‘relaxation rides’ as frequently as possible, in hopes that reduced time spent in the residential setting would diminish his overall level of agitation. In practice, ‘relaxation rides’ were feasible approximately twice daily. Ultimately, this programme proved problematic, as EB began to expect rides, but would quickly forget that he had already taken a ride; EB then accused staff of lying to him (e.g. when they informed him that he had already taken his relaxation ride for the morning). When strategies to document his rides were implemented, he accused staff of forging his signature. It was noted that new antecedents to agitation developed as a result of the ‘relaxation ride’ programme, including being asked to delay gratification (i.e. being asked to wait for a ride because of another client need), being reminded that he went on a relaxation ride already during that shift and/or cancellation or postponement of the ride because of inclement weather. Behavioural data indicated that, despite an increasing number of outings each month, verbal and physical aggression continued to increase in frequency over time. Scripting interactions In working with CW [9], it was noted that both denying and sympathizing with CW’s persistent belief that he had just woken up led to agitation and severe distress. It was suggested [9] that avoiding statements which typically led to CW’s routine response about just awakening was the best way to avoid agitation. In order to assist staff in avoiding or circumventing topics which typically served as antecedents to aggressions, clinicians provided ‘scripts/interaction guidelines’. For example, it was noted that sympathizing with EB’s current situation (i.e. living at a residential facility) led to EB becoming increasingly agitated, as did challenging EB’s assertion that he has never been violent or aggressive. Staff members were provided with verbal scripts about how to avoid topics that could lead to EB becoming verbally aggressive. However, staff found it difficult to enact the scripts when EB was agitated, because he accused them of ‘putting [him] off’ (i.e. he felt as though they were avoiding him and that his needs were not addressed, as he was unable to remember the conversations in which his

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questions were answered). On one occasion, EB became physically aggressive with a staff member who attempted to implement a script to avoid a discussion of EB’s financial concerns. Organization and finance management programme Prior to admission to the rehabilitation centre, EB left himself copious notes in order to organize his life; notes included information about what he had done that day, dates of future appointments and lists of people who he felt were trying to take advantage of him. Ultimately, he was unable to manage the large amount of information and was unable to access specific information when he needed it. Inability to recall information important for financial planning (i.e. how much money he had in his account, when he received his monthly social security income and how he had spent his funds during the prior month) frequently led to agitation and accusations that others were stealing from him. Early interventions were aimed at assisting him in becoming more organized. Specifically, EB was provided with a weekly ‘banking statement’, that tracked current funds and money spent during the prior month. Attempts to review these statements in person with EB were unsuccessful as he would accuse the reviewer of lying to him, thus increasing his agitation. The behaviour specialist began placing these statements by his door each week and also described when he would be receiving his next statement. With ongoing assistance from occupational therapists, speech and language therapists and behaviour services, EB did learn to keep important information in one small, handheld pocket calendar. He kept appointments and checked off activities once he completed them. He also used a large dry erase calendar in his room to help mark days when his monthly cheque would arrive. While these interventions were of some benefit, agitation and verbal aggression persisted when EB ran out of funds for the month. Attempts to redirect him to his banking statement when he was agitated proved unsuccessful in diminishing agitation. Overall, when interventions were put into place to modify the environment or target known antecedents, new antecedents to aggression would arise in response to the interventions. Providers often found themselves creating interventions to target aggression that was in response to the previous interventions. When interventions were terminated or abandoned, EB would then become angry that staff members were ‘switching up the rules’ again, which perpetuated his belief that those around him had malevolent intentions.

Insight-oriented interventions After interventions aimed at modifying the environment failed, EB’s treatment team attempted more elaborate insightbased interventions. Providers hypothesized that some capacity to understand what behaviour led to his placement in a residential setting could allow EB to focus on futureoriented goals (i.e. decrease aggression in order to increase independence) rather than being stuck in a cyclical argument about a delusionally-filtered past.

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Video recording intervention It has been reported [15] that the use of video recording was helpful in self-monitoring for individuals with orbitofrontal cortex (OFC) damage. Researchers [15] indicated that individuals with orbitofrontal cortex (OFC) damage were often able to describe appropriate social interactions, but failed to apply that knowledge in social interactions. Further, only when shown video recordings of their own interactions were subjects able to demonstrate insight (and indeed, embarrassment) about their behaviour. In an attempt to improve EB’s insight into his behavioural deficits, he was video-recorded while being confrontational and threatening towards a female staff member. The recording was accomplished by providing the staff member with reading glasses that contained a hidden camera, so that EB would be able to observe the perspective of the staff member with whom he was interacting (guardian approval was obtained in advance). However, this intervention proved unsuccessful, as EB became agitated about the content of the video while watching the video; in essence, he became agitated at the female staff member in the video as he replayed the videotaped interaction. He appeared incapable of retaining an understanding of the purpose of the intervention and instead began to threaten the clinician who showed him the video. When the clinician attempted to redirect EB toward the task by asking him if he felt that he looked threatening in the video, EB only became more agitated. A similar increase in agitation was observed by clinicians working with CW [10] when they attempted such an intervention. Time-line intervention When faced with the task of creating insight based-interventions for an individual with amnesia, EB’s clinicians attempted to tap into his relatively preserved capacity for learning music to inform future interventions. EB’s capacity for learning in the absence of explicit memory for the learned task was first noted when EB was listening to music. EB often referred to artists who were popular prior to the onset of his injury (e.g. the artist 2Pac). During his relaxation rides, EB was provided with a ‘relaxation CD’ containing songs from his preferred musical genre, including ‘new songs’ (i.e. songs released following his BI). EB preferred rap music and, therefore, clinicians worked to find rap songs with empowering lyrics that EB might be able to relate to. Interestingly, after repeated exposure to ‘new song’ lyrics, EB demonstrated the capacity to recite the lyrics verbatim when the music started to play. However, he demonstrated no recognition of the song when the music was not playing. Based on these observations about his ability to learn in the absence of remembering, a decision was made to attempt to teach EB his autobiographical history as a means of improving insight and, thus, therapeutic engagement. Failed attempts to teach new information to patients with HSVE have been described [16]. Specifically, it was reported that clients with memory impairment are not able to benefit from trial and error learning like clients without memory impairment, but instead benefit from being prevented from making a mistake when learning new information (i.e. errorless learning). Additionally, in a small study (n ¼ 4) researchers indicated that individuals with severe memory

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impairment secondary to the effects of HSVE (n ¼ 3) and semantic dementia (n ¼ 1) were able to learn and retain a piece of semantic information and link it with a picture of the 10 famous individuals [17]. However, it was noted learned information required ‘a significant number of training sessions’ and individuals with HSVE required more cues in order to generalize the skill (e.g. recognize the famous individual in a different picture provided during training sessions). Informed by an errorless learning paradigm, EB’s clinical team developed a strategy through which information about his history and treatment needs was provided to him in the form of a timeline, thus preventing him from rehearsing inaccuracies. Although a similar autobiographical intervention was unsuccessful with CW [10], based on the observations described above, it was hypothesized that EB might be capable of learning information about post-injury history that would increase his capacity to engage in treatment. With assistance from his guardian and family members, EB’s treatment team compiled a comprehensive family, educational, vocational, medical and criminal history. The information was combined with pictures from family and from the facility to make a pictorial timeline/album. Although EB did not present with severe retrograde memory impairments, information about childhood and early adolescence was included in order to obtain ‘behavioural momentum’ (i.e. behavioural strategy used to increase compliance): the clinicians hypothesized that once EB read information that he agreed with and knew to be true, he would be more likely believe later information for which he had no recall ([18], p. 123). Interestingly, when EB was presented with the timeline, he was able to sit down and read through the 20 page document without agitation or argument about the validity of its contents; this stood in sharp contrast with his behaviour when providers attempted to talk with him about his history. While this intervention succeeded in providing EB with a record of his behavioural problems, of how he came to live at his current facility and of how behaviour needed to change before he could move to a less restrictive setting, EB was not capable of recalling the contents of the timeline, even when cued. It was hypothesized that the information needed to be presented to EB several times daily for many months in order to ensure encoding and retrieval. Additionally, as studies have shown modest effects when learning simple and brief information, it is likely the information provided in the timeline was too complex and lengthy. Unfortunately, EB engaged in two significant assaultive events, resulting in police intervention, imprisonment and subsequent transfer to another facility. As a result, the authors were unable to continue this promising intervention.

Discussion Despite numerous reports in the literature describing neuropsychological consequences of HSVE, few descriptions of aggression and delusional ideation have been provided to date. This paper describes the challenges of applying a series of behavioural strategies and environmental modifications to address significant aggression in an individual with amnesia. Future interventions aimed at managing aggression in

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individuals with severe anterograde amnesia must avoid relying on the ability to learn from trial and error, but instead utilize errorless learning techniques. Furthermore, interventions with individuals similar to EB may include making a DVD for them to watch daily with similar information contained in their time-lines, along with music that matches the contents. This type of visual-audio intervention may tap non-declarative aspects of learning. In addition, the audio time-line may build off of both behavioural momentum and errorless learning as it provides the individual with correct information and minimizes the opportunity for him or her to make/reinforce incorrect information/narratives. The authors of this case study hope that failures and limited successes of the described interventions may be of use for clinicians working with amnestic clients, specifically clients for whom amnesia exacerbates agitation and aggression. Strategies that proved unsuccessful included those that required EB to understand and remember the purpose of the intervention in order to participate. EB responded best when given direct, clear and concise written information that left no room for confusion or ambiguity. Management of aggression in amnestic populations with relatively preserved intellectual capacities presents a challenge to clinicians working in the cognitive rehabilitation field and deserves the attention of future research. Additionally, given that individuals such as EB pose a significant challenge for clinicians and for the facilities in which they reside, they are at risk for abrupt transfers to more restrictive settings. Interestingly, the case of EB highlighted what the authors see as a systemic problem for individuals with brain injury who have significant problems with aggression. Those who worked with EB agreed that it was no longer appropriate for him to stay at the residential facility, given his escalating aggression and the associated risks to residential staff and other residents. The other options available to him were insufficient—inpatient psychiatric hospitalization would not provide a long-term solution and placement in a correctional setting would not be appropriate, as his cognitive impairments made him unable to appreciate the gravity of his behavioural problems, while also leaving him vulnerable to exploitation by others in the correctional setting. Although the systemic problems associated with the gap between brain injury rehabilitation, mental health and forensic services are beyond the scope of this paper, they remain an important consideration for providers in the field.

Acknowledgements We would like to acknowledge the dedicated clinical team and residential staff at Lakeview Neurorehabilitation Center, who provided countless hours in assisting with implementation of the interventions described in this article.

Declaration of interest The following paper was authored by Tracy E. Shannon PsyD and Stefanie L. Griffin PhD. The authors report no conflicts of interest. Dr Shannon was the primary author and Dr Griffin was the secondary author. Order of authorship was discussed

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prior to journal submission. Dr Shannon worked at Lakeview Neurorehabilitation Center as a behaviour specialist for the majority of the study. During 1 year of the study, Dr Shannon worked as a pre-doctoral intern at Lakeview Neurorehabilitation Center. Dr Griffin was the director of training and the primary supervisor of Dr Shannon during the study. Prior to the initiation of the study, approval and permission was obtained from the Human Rights Committee at Lakeview Neurorehabilitation and from the guardian of the study participant.

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Appendix: Neuropsychological test results.

WAIS-IV Verbal sub-test Similarities Perceptual reasoning sub-test Block Design Matrix Reasoning Working memory sub-test Digits Forward Processing speed sub-test Coding WMS-IV sub-test Logical Memory I-Immediate Logical Memory II-Delayed

Scaled score Mean ¼ 10 SD ¼ 3 4 13 10

Descriptor Borderline impaired

Percentile rank 2

High average Average

84 50

9

Average

37

7

Low average

16

2 1

Impaired Impaired

0.4 0.1

Rey-Osterrieth Complex Figure Test

T-score Mean ¼ 50 SD ¼ 10

Descriptor

Percentile rank

Time to Copy Copy Immediate Recall Delayed Recall

26 54 0 0

Impaired Average Impaired Impaired

1 67 50.1 50.1

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Managing aggression in global amnesia following herpes simplex virus encephalitis: The case of E.B.

This article describes an integrative approach to the case of EB, a 33 year old male who presented with agitation, delusional ideation and global amne...
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