Introduction
To begin, I wanted to talk about Phineas Gage. He was one of the first documented cases where psychological changes occurred following a traumatic brain injury (TBI). Phineas Gage was an iron worker in the 1800s. In 1848, he had an accident where an iron bar went through his skull into his frontal lobe. After the injury, he displayed personality changes. He was described as going from a "responsible and socially well-adapted man to someone who was negligent, irreverent, and profane, unable to take responsibility". At that time, Adolph Meyer coined the now defunct phrase "traumatic insanities" to refer to cases where the injured person exhibited alterations of consciousness, psychosis, and neurological symptoms (Schwarzbold et al, 2008; Damasio et al., 1994; Neylan, 2000).
Definitions
According to the World Health Organization (1996), acquired brain injury (ABI) is damage to the brain occurring after birth and is not related to a congenital or a degenerative disease. The impairments may be temporary or permanent and cause partial or functional disability or psychosocial maladjustment. ABI includes traumatic and non-traumatic causes, as well as anoxia, hypoxia, stroke, any other sort of brain disease.
The American Psychiatric Association defines psychological health (PH) disorders or mental illnesses as "health conditions involving changes in thinking, emotion or behavior (or a combination of these)". Furthermore, "mental illnesses are associated with distress and/or problems functioning in social, work, or family activities". Some examples of mental illnesses include:
- Major depressive disorder (MDD)
- Attention deficit hyperactivity disorder (ADHD)
- Schizophrenia: A severe mental disorder, characterized by profound disruptions in thinking, affecting language, perception, and sense of self. It often includes psychotic experiences, such as hearing voices or delusions. We'll talk about how symptoms of schizophrenia mirror TBI.
- Personality disorders: Enduring maladaptive patterns of behavior cognition and inner experience. Examples of personality disorders include narcissistic personality disorder, avoidant personality disorder, and borderline personality disorder.
Cognitive/Communication Symptoms
Typical cognitive communication symptoms of ABI can affect a person's:
- Attention
- Memory
- Executive functioning
- Complex problem solving
- Language
- Word finding
- Aphasia
- Pragmatics
- Stuttering (typically psychogenic in nature)
There are many cognitive symptoms that are shared between individuals with ABI and psychological health issues (Whiting et al., 2017). These symptoms include problems with:
- Executive Dysfunction: This involves difficulties with recognizing a task that needs to be done, planning how you're going to do it, completing it, and having the self-awareness to know how you did (being able to monitor and evaluate your performance).
- Attention: Inability to maintain sustained attention (paying attention over a long period of time), selective attention (focusing on one thing amid distractions), and divided or alternating attention (switching attention between more than one task).
- Immediate, working and delayed memory (as observed during cognitive screenings)
- Immediate memory: Being able to recall five words right now, or repeat after me
- Delayed memory: Being able to recall something after a five to 10 minute delay
- Working memory: Involves serial numbers (e.g., starting at 100, subtract seven and keep subtracting seven from each resulting number); remembering what you're doing as you go along.
- Pragmatics: Our social language and social skills, and eye contact, and behavior.
Most Common Psychological Health Disorders Following ABI
According to Finnanger and colleagues (2015), the most common psychological health disorders following ABI are:
- Anxiety
- Mood Disorders (Major Depressive Disorder)
- Bipolar Disorder
- Attention Deficit Hyperactivity Disorder (ADHD)
- Substance Abuse
- Post-Concussion Syndrome
One thing to note is that in general, ADHD is diagnosed in childhood, so there is some evidence that folks who have the diagnosis of ADHD from childhood are at a greater risk to sustain a traumatic brain injury because of some of that impulsive behavior. If someone has survived a TBI, and they now have symptoms of an attention disorder, it's questionable whether these symptoms can be diagnosed as ADHD, because it's a symptom of the person's traumatic brain injury. Mood disorders and major depression entail a persistent feeling of sadness or a lack of interest in anything outside of yourself. We'll talk through how some of those things can impair memory, attention in particular. Bipolar Disorder is alternating periods of high and low (elation and depression), and the person's mood continually changes.
Cognitive Symptoms of PH Disorders
The cognitive symptoms of a person with a PH disorder include:
- Memory
- Attention
- Problem Solving
- Executive Dysfunction
You're going to see all of those symptoms in people with bipolar disorder, major depressive disorder, and schizophrenia. Schizophrenics are very susceptible to executive functioning difficulties. Those with major depressive disorder primarily have memory and attention issues. Individuals with ADHD, of course, have the attention component, as well as problems with executive dysfunction.
Factors Influencing PH Disorders
According to Jorge & Arciniegas (2014), factors that contribute to a person developing psychological health disorders after TBI include:
- Genetic predisposition
- Circumstances surrounding the event or trauma
- Social support following the injury
- A pre-injury history mental health disorders (these individuals have a higher incidence of more persistent symptoms after brain injury)
Cognitive Flexibility vs. Psychological Flexibility
I wanted to differentiate between cognitive flexibility and psychological flexibility. For those of us who work with survivors of brain injury, cognitive flexibility (also known as mental flexibility) is a term that we are very familiar with. It is the ability to shift and change and is a component of executive functioning. It includes planning, problem solving, performance assessment, and path correction (similar to the definition of executive functioning).
Psychological flexibility is the ability connect with the present moment and experience the thoughts and feelings without unhelpful defense, and to persist in action that is consistent with values, or change that action when the situation demands. In other words, it involves more the ability to cope with the emotional impact of the injury, and it's a core mechanism of change contributing to mental health. Being able to shift from where you were prior to the injury, in terms of your emotions and mental health, and then, being able to accept where you are now post-injury is an example of psychological flexibility. If anyone has ever been in psychological therapy or counseling, psychological flexibility is often one of the focuses of treatment, because they want folks to shift between where they are now and where they potentially could be in the future.
Differential Diagnosis
How do you tell if symptoms are a result of brain injury or psychological health disorders? Speaking from experience, sometimes we'll get a referral for a patient that has a diagnosis of depression, where they appear brain injured (e.g., having memory difficulties or word finding problems, inability to attend to my questions). According to the Medical Dictionary for the Health Professions and Nursing, "Differential diagnosis is distinguishing between two or more diseases with similar symptoms, by systematically comparing their signs and symptoms." It's important when considering psychological health diagnoses following Acquired Brain Injury to have that differential diagnosis piece. For example, some patients may display repetitive behaviors due to memory problems, or perseveration as a consequence of executive function issues that resulted from their brain injury. If they exhibit those symptoms, how do we tell if their executive function is impaired due to brain injury, or whether they have OCD? Chances are you would have diagnosed that person with OCD, but it may be symptoms resulting from the brain injury. Similarly, if a patient has attention deficit issues following a brain injury, are we going to diagnose that patient with ADHD or determine that they have attention symptoms following their injury? The DSM-V (Diagnostic and Statistical Manual of Mental Disorders), differentiates cognitive and other problems related to TBI (e.g., mild or major neurocognitive disorder).
Next, Schweiger and Brown identified what is known as Organic Brain Syndrome (OBS). According to Dictonary.com, OBS refers to "any of a group of acute or chronic syndromes involving temporary or permanent impairment of brain function caused by trauma, infection, toxin, tumor, or tissue sclerosis, and causing mild-to-severe impairment of memory, orientation, judgment, intellectual functions, and emotional adjustment" (2002). Organic means that the impairment is from a physical cause. Schweiger and Brown emphasized that it is important to differentiate between if the impairment is organic, or if it is indeed a mental impairment, in order to help with treatment. If someone has an attention issue resulting from a brain injury, we might be able to give them medication to assist with focusing. However, if it's a result of depression or schizophrenia, that person will need different medication, and attention may not be the primary focus of treatment.
Treatment
If you're treating patients who may have more of a psychological health impairment than brain injury impairment, you're going to want to work with neuropsychology, psychology, social work and psychiatry, as well as your rehab team, comprised of SLPs, OTs, and PTs. Often, these disorders are co-morbid, occurring together. It is important to work as part of an interdisciplinary treatment team in order to get the support you need, if the impairment involves more of a behavioral component due to psychological health issues. I do realize that not everyone works in a facility where psych professionals are readily available. Perhaps you work in acute care and you don't have the time to go and collaborate with different psych professionals, but it's definitely a great thing to have in your back pocket if you have that opportunity.
The best approach to treatment for these patients is a functional and evidence-based approach. If it's determined to be a cognitive cause or a co-morbidity, you're going to evaluate and treat based on symptom, patient goals, and patient psychological needs. When I was working at a Department of Defense facility, most patients had a co-morbid diagnosis of at least a mild or moderate TBI, and a psychological health disorder, such as post-traumatic stress disorder (PTSD). A big part of our treatment was working together with social work, with psychiatry and psychology to determine what part of the symptoms were from brain injury, what parts were more psych-based. I worked with a former Sniper who was struggling with PTSD, but he had also sustained multiple blast injuries. He had lots of attention issues. He was also very hypervigilant, which does not contribute in a positive way to his attention issues. I worked with our psych team to reinforce what they were teaching him, which included doing exercises that were tied directly to his sniper training, such as slowing his heart rate and breathing (which helped him to attend in certain distracting environments).
Psychological Treatment
As SLPs, it is important to note that psychological treatment is outside of our scope. However, when treating folks with brain injury, we do need to keep in mind some of their psych health goals. Per Schwarzbold and team (2008), the treatment for the majority of psychological and psychiatric disorders is primarily the same after ABI as before, whether that involves medication based treatment or cognitive behavioral therapy (2008). We need to be cognizant of the brain injury/psychological disorder continuum, as a patient may have both diagnoses. We need to be able to work with the team to figure out appropriate goals for each patient.
It is worth noting that as SLPs, counseling is within our scope of practice, however, not for chronic mental illness. In fact, SLP graduate programs are now working to incorporate more of the counseling piece into the curriculum. Some of the main components of counseling include active listening, refraining from direct questioning that may create insecurity, and working with the patient to develop goals. You want that collaboration. You want to be open-minded. Even if the patient tells you a goal that may not be appropriate, we need to help guide them to a point where they can develop a more realistic goal.
Post-Concussion Syndrome and Chronic Traumatic Encephalopathy
I wanted to talk a bit about psychological health issues related to post-concussion syndrome (PCS) and chronic traumatic encephalopathy (CTE).
Post-Concussion Syndrome (PCS)
Post-concussion syndrome is a complex disorder in which various symptoms, such as headaches and dizziness, last for weeks and sometimes months after the injury that caused the concussion. You don't have to lose consciousness to get a concussion or post-concussion syndrome. In fact, the risk of post-concussion syndrome doesn't appear to be associated with the severity of the initial injury. In most people, symptoms occur within the first seven to 10 days and go away within three months. Sometimes, they can persist for a year or more (mayoclinic.org).
Post-concussion symptoms include:
- Headaches
- Dizziness
- Fatigue
- Irritability
- Anxiety
- Insomnia
- Loss of concentration and memory
- Ringing in the ears (tinnitus)
- Blurry vision
- Noise and light sensitivity
- Rarely, decreases in taste and smell
The thing that differentiates PCS from typical recovery for brain injury is that in many cases, both the physiological effects of brain trauma and emotional reactions to those effects play a role in development of symptoms. Those symptoms continue beyond what the normal continuum of their recovery should be. If someone who had a mild TBI concussion is still struggling with attention issues a year later and they haven't had an additional hit, it may be due to PCS (Hoge et al., 2008; Meares et al., 2008).
The prevalence of a pre-injury psychological disorder (usually an anxiety or affective disorder) is high in those with PCS. There is already a baseline of psychological health issues prior to their concussion/TBI. When you're looking at patient histories, keep in mind that acute PCS symptoms can be found in mild Traumatic Brain Injury and non-brain injured trauma patients. It's important to use caution when attributing health problems to mild TBI, as you need to be aware that things such as PTSD and depression may be their primary problem. It's an important point because TBI typically does occur in the context of a traumatic event. As such, psychological stress will probably be influential in some of these recoveries (Hoge et al., 2008; Meares et al., 2008).
Chronic Traumatic Encephalopathy (CTE)
According to Boston University’s Chronic Traumatic Encephalopathy Center, CTE is a progressive degenerative disease of the brain found in people with a history of repetitive brain trauma (often athletes), including symptomatic concussions, as well as asymptomatic subconcussive hits to the head that do not cause symptoms. CTE has been known to affect boxers since the 1920s when it was initially termed "Punch Drunk Syndrome" or "Dementia Pugilistica." As of now, it can only be diagnosed after death via brain autopsy.
A recent study by Dr. Goldstein at Boston University showed that the number of hits, not the number of concussions, is what causes CTE, even if those hits are subconcussive (2018). If you are an athlete or in the military, and have sustained multiple hits to the head, whether you have lost consciousness or not, those hits have the potential to impact your cognitive functioning down the road.
In January of 2018, the television show "60 Minutes" aired a piece featuring Dr. Ann McKee, also of Boston University. In the segment, Dr. McKee discusses recent findings of CTE in the military: that service members and veterans who have sustained multiple blast injuries are now showing symptoms of CTE.
Symptoms of CTE include:
- Memory loss
- Parkinsonianism
- Confusion
- Aggression
- Depression
- Suicidality
- Progressive Dementia
Some of these symptoms are indeed psychological health disorders (e.g., depression), again demonstrating the overlap in organic brain disease and psychological health factors. Furthermore, the degeneration of the brain leads to an increase in Tau proteins, which is exactly what occurs in Alzheimer's tangles.
