by Robert C. Bransfield, M.D.
This is the fourth article in a series addressing the effects of Lyme disease upon mental functioning. Topics currently being researched include autism, automobile accidents, and Lyme family dynamics.
Several years ago, I admitted a patient with Lyme disease (LD) to a psychiatric unit. He was paranoid and assaulted five police officers in an episode of rage. During the hospital stay, the patient went to the river behind the hospital to watch the Fourth of July fireworks display. When the fireworks began, the patient jumped into the river. It appeared the loud noise was responsible for an acoustic startle reaction.
At the same time, a female patient with LD was also on the unit. She described puzzling symptoms that consisted of episodes of rage and intrusive, horrific homicidal images. In both cases, the aggressive tendencies improved with treatment.
In reviewing cases involving LD patients, another patient described an incident where someone else pulled into a parking space that he wanted. Jumping out of his car, he knocked the other driver unconscious. Still another patient stated he was driving on the highway when a motorist beeped their horn. He lunged out of his car and began pounding on the windshield of the car, then suddenly stopped in bewilderment because he did not understand or recall why he was behaving in this manner.
A female patient was arrested for shoplifting during a state of confusion. Another patient was accused of pedophilia. I can cite many more examples. When we look at cases of aggression associated with LD, were all of these cases merely a coincidence or a causal relationship between LD and some of this aggressive behavior?
After methodically interviewing hundreds of patients over a period of years, it was clear that certain patterns were emerging. The same problems were being seen in too many patients. A causal link was becoming increasing apparent. I would like to emphasize that the vast majority of patients who know they have LD are not violent. It is not my intention to draw attention to an issue that further increases the stigma that LD patients already receive. However, it is my intention to methodically look at the association that does seem to exist between LD and aggressive behavior in a minority of chronic LD patients.
Clearly violence is a very complex issue. Many different factors have contributory or deterrent effects. One study of death row inmates demonstrated that 100% were neurologically impaired. Many also had a history of abuse. Sometimes the abuse precedes or causes the neurological impairment. Sometimes the neurological impairment precedes or causes the abuse. Neurological impairments and abuse either alone or in combination are significant risk factors that increase the potential for violence. Other risk factors are significant in some cases.
A triggering event(s) may then occur which provokes violent behavior in a person who is at risk. A normal person given the same level of provocation does not act in a violent manner. In some cases, the trigger is an intrusive, violent image, an obsession or compulsion to do harm, or it may be a perception of threat.
In addition to a provocative factor, there are many deterrents to violence, which include a neurological capacity for restraint, social bonding, victim response, and social structures. When violence occurs, we need to consider some combination of increased risk factors, triggering events, or a failure of deterrents to violence.
It is well recognized that LD causes dysfunction of the central nervous system (CNS). Many other conditions which cause CNS dysfunction are sometimes also associated with violent behavior, i.e.: strokes, brain tumors, lupus, MS, head injuries, developmental disabilities, carbon monoxide poisoning, syphilis and other CNS infections. When reviewing the pathology associated with aggression, we can see dysfunction of a number of different brain areas.
To briefly review the physiology, there is a hierarchy of functioning within the CNS, which has developed through evolution. When we go from the most advanced to the most primitive areas of the brain, the hierarchy consists of the prefrontal cortex, other cortical regions, para limbic associative areas, the limbic system, and the brain stem and hypothalamus. These centers function together with many feed forward and feed back pathways that are both stimulatory and inhibitory. Injury to a higher center can result in a dysfunction or a loss of a function. Injury to an inhibiting pathway will cause a decline or an inability to inhibit that function. As a result, brain injury leads to a decline in our ability to fine-tune our adaptive abilities in an effective manner.
In the case of aggressive functioning, injury can lead to apathy (a failure of stimulation) and/or aggression (a failure a inhibition, modulation, or association) Since circuits controlling aggression are often parallel with sex and feeding, we often see aggressive disorders in combination with sexual dysfunction and eating disorders. Different patterns of brain injury result in different patterns of symptoms.
Now let's look at the association between Lyme and aggression. The first reference on this subject in the medical literature I could find was made by Fallon, et al in 1992 in 'The Neuropsychiatric Manifestations of Lyme Borreliosis", in which he described a man acutely sensitive to sound was so intensely bothered by the noise his three-year-old son was making that he picked him up and shook him in a sudden and unprecedented fit of violence. Other cases can be found in medical literature cited at Lyme meetings and in newspaper reports. The phrase "Lyme rage" continues to appear on the Internet. There are discussions that some "road rage" is caused by "Lyme rage".
I would estimate aggressive behavior has been a significant issue for approximately fifty patients with LD that I have evaluated or treated, although many more have reported some symptoms associated with aggressive potential. When aggression does occur, it may only be present for an interval in the progression of the illness.
Deficits caused by LD that are sometimes associated with increased risk for aggressive behavior may include:
Decreased frustration tolerance. (This is magnified by the increased frustration caused by a chronic illness).
Decreased impulse control.
When mild, the combination of decreased frustration tolerance and decreased impulse control leads to irritability. When more extreme, this combination can result in explosive anger.
Hyposexuality and hypersexuality caused by LD, both of which cause increased interpersonal frustration.
Dysfunction causing different forms of obsessive compulsive disorder, which results in intrusive thoughts, images, and compulsions that sometimes are of an aggressive nature.
Some dysfunction results in a decreased bonding capacity.
Increased startle reflex - particularly increased acoustic startle.
Hypervigilance and paranoia.
Delusions and hallucinations.
Some patients acquire impairment in their ability to regulate the arousal level of an emotion. As a result, emotions such as anger may be all or none, excessively intense, and not proportionate to the current situation. This also leads to a decline in the ability to integrate concurrent emotions that exist either within the patient or in a relationship with another person. This symptom may in turn intensify other psychiatric syndromes such as post-traumatic stress disorder, dissociative disorders, borderline personality, and narcissistic personality disorders.
Any combination of the above impairments can result in aggressive behavior. When these changes occur in a mature adult, the patient is surprised by the symptoms - they recognize it is pathological and attempt to compensate for the deficits. However, children who never had the reference point of a mature level of functioning are at a greater risk. Some of the most threatening cases were patients who were infected at a young age.
The following is a quote from a patient describing horrific intrusive images, which many patients with Lyme have described to me:
"Frightening, stabbing, horrific images - usually of death, dying or pain and suffering. Often gory and unreal as in a horror story. Faces mostly with blood or terror exaggerated awful expressions. Visions of stabbing or killing often of those close to you or familiar. These penetrating images add to the already anxious condition of a Lymie. Episodic, not continuous. Fleeting faces most usually of the worse possible situation. Helpless stumped bodies perhaps close to death. These images don't seem to necessarily be associated with a particular occasion, place or time, but come and invade the privacy of my mind. Control over physical well-being is lost with Lyme, but much more disturbing and debilitating is the lack of control or normalcy of the mind both emotionally and cognitive - perhaps worse during a flair when all symptoms often rear their ugly heads. It is a crushing experience to survive these images feeling possessed or evil. If they were to be continuous and not fleeting, no-one could or would survive."
In another case, a patient had no prior history of mental illness suicidal or homicidal tendencies. The patient went to their HMO primary care physician complaining of an apparent tick bite. It is reported that the doctor neither sent the patient for testing nor initially offered antibiotic treatment. As symptoms progressed, the patient was diagnosed with fibromyalgia. Subsequent symptoms included word substitutions, getting lost, losing items, and an inability to find their car in a parking lot. Eventual tests confirming LD included a Western Blot, brain SPECT, and an ophthalmologic exam.
The patient improved with treatment of several weeks on IV antibiotics and was stopped as per the managed care guidelines. The patient relapsed and further IV treatment was denied. Their mental state declined and subsequently there was a combined homicide-suicide.
In conclusion, based on my observations and clinical judgment, chronic relapsing LD at times causes aggressive behavior, which can manifest in a number of different forms. Since this is aggression associated with a CNS infection, it can potentially be treated and prevented. If only a small percent of chronic LD patients are affected, the total number of cases is still quite significant. Since this is a late stage manifestation, the increasing number of individuals infected with Bb raises serious concern that violence associated with or caused by LD will increase in the future.
What can we do now to prevent a possible future epidemic of violence? Suggestions include high index suspicion for Lyme disease in rageful people, adequate testing for Lyme disease in those who are enraged, adequate treatment of LD, continued LD advocacy efforts, research into the link between aggression and LD, evaluation of violent offenders who demonstrate some of the aggressive patterns seen with LD prior to their release into the community, and vaccinations. When regional epidemics of violence occur, LD and other causes of encephalopathy should be considered. We should exercise every option to prevent crime with medical treatment.
If anyone has information relevant to this issue, I invite him or her to write subsequent articles.
Letter to the Editor
Dear Sir or Madam:
I have worked with mental health patients over a 41-year span. I have seen in my private office a fair share of people who have experienced anger at spouses, bosses or friends. I would like to bring to your attention that over the last few years, however, this behavior has had a different quality. "My wife/husband has had a sudden personality change", the caller will begin. "and he/she was so angry he/she broke down a door." Or I will hear, "My husband/wife is acting in an uncharacteristic way. Usually kind, she/he furiously lashes out at people in ways that even surprise her/him", "she curses loudly at other drivers for the first time ever" or "I think she/he invented road rage". The thing these incidents seem to have in common is the episodic turnaround of usual and expected patterns of people of known character.
Closer questioning now often reveals a plethora of unusual symptoms for which the person has not found a diagnosis. Some of these are sleep attacks, fatigue, mood changes. muscle pains, hypersensitivity to sounds and light, GI distress, and many "soft" neurological signs such as transient numbness, itching, restless legs, insomnia, etc. I had two people in one day tell me they stopped their car cold in the middle of a busy highway and "woke up" with other cars veering around them!
While only a few of such people recall a tick bite or rash, when they are tested in a sensitive laboratory, most of these people check out positive to one or more of Lyme disease, ehrlichiosis and/or babesiosis. They do respond to the appropriate anti-infective medication, then the rages melt away with or without psychiatric medication. Relief from these inappropriate outbursts is of real satisfaction to the patient and the therapist, although the patient sometimes doesn't spontaneously notice the change in himself and continues to feel the previous behavior the fault of the others involved.
Tick-borne rages are epidemic now and should be checked for by every physician and every Lyme disease patient.
Very truly yours,
Virginia T. Sherr, M.D., F.A.P.A