Aggression and Lyme Disease
by Robert C. Bransfield, M.D.
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
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
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?
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
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
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
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:
1. Decreased frustration
tolerance. (This is magnified by the increased frustration caused by a chronic illness).
2. Decreased impulse
3. When mild, the
combination of decreased frustration tolerance and decreased impulse control leads to irritability.
When more extreme, this combination can
result inexplosive anger.
4. Hyposexuality and hypersexuality caused by LD, both of which cause
increased interpersonal frustration.
5. Dysfunction causing different forms of obsessive compulsive disorder, which results in
intrusive thoughts, images, and compulsions that sometimes are of an aggressive nature.
6. Some dysfunction results
in a decreased bonding capacity.
7. Increased startle reflex - particularly increased acoustic startle.
8. Hypervigilance and paranoia
9. Delusions and
10. 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
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
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 Lymey. 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 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
If anyone has information
relevant to this issue, I invite him or her to write subsequent articles.