Providentia

Is There a Link Between Brain Injury and Psychiatric Problems?

An interesting analysis in the December 2007 issue of Brain Injury looks at the role of traumatic brain injuries (TBI) in the development of severe, long-term psychiatric disorders.

While a clear causal link remains unclear, the authors found that psychiatric syndromes are consistently present at an elevated rate following TBI. Survivors of TBI are particularly susceptible to major depression, generalized anxiety disorder and post-traumatic stress disorder. While evidence of a direct link is lacking, the authors suggest that there may be consistent critical periods for the post-injury development of psychiatric disorders that have yet to be identified. There is evidence, however, that TBI cases remain at risk for years following injury. Non-organic factors, including pre-morbid personality traits and post-injury psychological reactions to disability and trauma, seem to play a role in the development of post-TBI psychiatric disorders. Treatment professionals dealing with TBI cases needed to be aware of the potential for the development of post-TBI psychiatric problems.

Click here for the abstract.

Ten Years After Traumatic Brain Injury

A research study published in the March 2008 issue of the Journal of the International Neuropsychological Society presents the results of a 10-year study examining the long-term effects of traumatic brain injury (TBI). Previous research investigating long-term has yielded mixed results linking severity of injury, demographic factors, and psychiatric problems. In the present study, a sample of 60 participants who had sustained TBI 10 years previously was used. Participants were tested with the Extended Glasgow Outcome Scale (GOSE) as well as neuropsychological measures of attention, speed of processing, memory and executive function and a measure of anxious affect. Outcome on the GOSE ranged from upper good recovery (32%) to lower severe disability (2%). Factors associated with poorer outcome on the GOSE included duration of posttraumatic amnesia, level of education, poor performance on cognitive measures of information processing speed, attention, memory, and executive function as well as showed higher levels of tested anxiety.

Click here for the abstract.

Does Mild Traumatic Brain Injury Cause Cognitive Problems?

A study reported in the December 2007 Journal of Psychosomatic Research examined cognitive complaints in head-injured patients referred to the emergency department of a level 1 trauma center in the Netherlands.  A sample of 79 patients (ranging in age from 18 to 60) who had been admitted for mild traumatic brain injury were followed up over six months post-admission. In addition to a battery of neuropsychological tests and use of the Rivermead Postconcussional Symptoms Questionnaire (RPSQ), patients were also asked to self-monitor their cognitive and memory problems over a 12-day period. Results indicated that 39 per cent of the sample self-reported cognitive problems. These complaints were strongly related to lower educational levels, emotional distress, personality, and poorer physical functioning (especially fatigue) but not to actual extent of injury.  Severity of self-reported cognitive complaints was found not to be associated with the patients' daily observations of cognitive problems or with outcome on a range of neuropsychological tests.  The researchers concluded that self-reported cognitive complaints were more strongly related to preexisting personality factors, as well as physical and emotional problems rather than actual cognitive impairments. This would suggest that treatment of emotional distress and fatigue may also reduce cognitive complaints. They also concluded that neuropsychological screening and daily monitoring of complaints is a useful method to gather information about the frequency and pattern of cognitive problems in regular life.

Click here for the abstract.

The Unforgettable Shereshevsky

It all began with a daily meeting at a newspaper in Moscow, sometime in the 1920s.

The editor was handing out assignments to the various reporters and was annoyed to note that one of the newer reporters had neglected to bring along a notebook. Solomon Shereshevsky (sometimes spelled Sherashevsky), then 29 years old, was quietly listening to the editor speak while all of his fellow reporters were busy writing down their assignments. The editor had noticed this before and decided to give his employee a scolding for not paying proper attention. When meeting him afterwards, the editor was astonished to find that Shereshevsky was able to remember every detail of the meeting with perfect accuracy. The journalist was just as astonished at his editor's reaction since he thought his perfect memory was normal. Always on the lookout for an interesting story, the editor decided to send his reporter to the local university for testing. It was there that Solomon Shereshevsky met Alexander Romanovitch Luria and an amazing collaboration began.

Over the course of the next 30 years, Luria would carry out an extensive series of experiments examining the journalist who would become his most famous case. Solomon Veniaminovitch Shereshevsky (identified only as "S" in Luria's writings) was born in Latvia and was part of an accomplished family (his father was a bookstore owner who could recall the location of every book in the store while his mother knew much of the Torah by heart). Although he had originally trained as a violinist, Shereshevsky became a journalist after an ear infection ended his musical career. Given his perfect recall, conventional memory testing was impossible but Luria was able to detail the processes underlying how Shereshevsky was able to memorize details so accurately. During the research trials, Shereshevsky was able to recall extensive lists of words, numbers and even nonsense syllables without mistakes and with only occasional hesitation. He could also report the numbers or letters in reverse order and could retain the information, seemingly indefinitely. Even events from early childhood could be recalled (including things that happened when he was still in his crib). There also appeared to be no limit to his digit span (as opposed to the seven to nine items that most humans can manage).

Based on his research, Luria concluded that Shereshevsky possessed an extreme form of synaesthesia which he used to convert various stimuli into visual images. It was this visual imagery that was one of the key factors in his astonishing recall. Whatever he was asked to remember, he would first mentally convert into visual images but often needed extra time to make the conversion. The perfect recall only failed when this process was disrupted in any way. He was even able to convert music and numbers into visual imagery by imagining the tones or numbers visually.

There were some intriguing limits to what Shereshevsky could remember however. He had a surprisingly poor memory for faces or voices heard over a telephone. He also had difficulty with abstract logical concepts and metaphors and often appeared slow and forgetful to others meeting him. His synaesthesia made him acutely sensitive to changes in his environment (for him to enjoy food in a restaurant, there had to be the right kind of background music playing).

Alexander Luria published his research results in 1968 as The Mind of a Mnemonist: A Little Book about a Vast Memory which has since become one of the great classics of psychology. He died in 1977 after an accomplished career as a neuropsychologist.

As for Solomon Shereshevshy? His amazing memory was also a serious handicap since his visual imaging meant that he frequently spent his life in a nonstop daydream. He gave up his journalism career and became a professional mnemonist giving regular shows to paying audiences. Despite his success, he never had great satisfaction as a performer and gave it up after a while. The last reference that I could find on him was that he became a taxi driver in Moscow but his life faded into obscurity afterward. Aside from a possible death date in 1958, there seems to be little else available.

By his own reckoning, Shereshevsky viewed himself as a failure in life since he was unable to use his vast memory in a way that he found personally fulfilling. He had wanted to be remembered for accomplishing something "great" in his life and, given his place in the history of psychology, may have succeeded. In 1998, Peter Brook released a theatre production based on Shereshevsky titled Je Suis Un Phenomene (I am a Phenomenon). Solomon Shereshevsky will be remembered.

Head Injury and Substance Use in Teenagers

A paper published in the January 2008 issue of Journal of Pediatric Surgery contains the results of a study examining the role of drug and alcohol use in adolescents suffering from traumatic brain injuries. Using trauma registry data to identify adolescent blunt trauma victims between 2000 and 2005, demographic information, injury severity, length of hospital stay, and clinical outcomes were evaluated. Of the total number of adolescent patients sampled, 9.3% tested positive for drug and/or alcohol use (the mean age of toxicology-positive patients was 17.2 years). The most commonly detected drugs were cannabis (40%), alcohol (30%), and polysubstances (23%). Substance-positive patients were more likely to be comatose, to have more significant injuries, and require emergency operations than adolescent patients who did not test positive for substance use. Length of hospital stay was was also significantly longer. In terms of outcome, mortality was found to be significantly higher and functional independence was lower. The authors conclude that substance abuse was linked to injury severity, need for medical care, and poor medical outcome for adolescent blunt trauma victims.

Click here for the abstact.

What Causes Postconcussion Syndrome?

The causes, diagnosis and outcome of postconcussion syndrome (PCS) remain controversial, especially following mild traumatic brain injury (mTBI) . An article in the August 2007 issue of the Journal of Neurology, Neurosurgery and Psychiatry describes the results of a prospective study examining the role of preexisting psychiatric disorders, demographic factors, injury-related characteristics, neuropsychological and psychological variables in shaping acute PCS. Using a sample of 90 traumatic brain-injured admissions to a Level 1 trauma hospital and 85 non-brain injured trauma controls, participants were given a battery of neuropsychological and psychological tests and a PCS checklist. Statistical analyses were used to predict acute PCS after 5 days postinjury. The results indicated that diagnosis of acute PCS was not specific to mild traumatic brain injury (mTBI 43.3%; controls 43.5%). Pain was found to be a significant factor but the the strongest predictor for acute PCS was previous history of affective or anxiety disorder. Females were 3.33 times more likely than males to experience acute PCS but the role of acute posttraumatic stress and neuropsychological function was relatively small. Higher IQ was also associated with acute PCS. The authors concluded that there is a high rate of acute PCS in both mTBI and non-brain injured trauma patients and that PCS was not found to be specific to mTBI. For this reason, the use of the term PCS may be misleading as it incorrectly suggests that the basis of PCS is a brain injury.

Click here for the abstract.

Awful Disclosures

It was in 1836 that a book was published in New York that seemed tailor-made to touch off a moral panic. Titled The Awful Disclosures of Maria Monk or The Hidden Secrets of a Nun's Life in a Convent Exposed, the purported author of the book, an ex-nun named Maria Monk provided lurid descriptions of her life in a Montreal convent and the sexual exploitation that she faced there. According to the book, she and other nuns of the Sisters of Charity of the Hotel-Dieu (also known as "the Black Nuns"), were routinely sexually abused by the priests at a seminary next door. Using a secret tunnel that linked the convent to the seminary, priests would enter to have sex with the nuns on a regular basis. If children resulted from the sexual acts, the babies would be baptized and then "smothered or secretly buried in the cellar". Nuns who refused the sexual advances of priests would be murdered. Maria said that she had stayed in the convent for seven years before becoming pregnant by a priest. It was fear for her child's life that finally caused her to flee Canada and go to the United States for safety and to give birth to her child.

Certainly the time was right for such a book to be widely accepted. Due to the influx of Irish immigrants, there was considerable anti-Catholic sentiment in the United States during that period and dark rumours about Catholic clergy and their hidden vices were widespread. Two years before the Monk book came out, another "tell all" book about life in a convent published by ex-nun Rebecca Reed had come out with allegations of forced conversions and abuse. At the same time, a convent in Massachusetts had been burned to the ground by a mob following rumours of a former nun being held against her will there. The publication of Maria Monk's book fed into the hysteria nicely and generated a tremendous outcry with calls for the investigation of the convent by leading Protestants in New York and Montreal. An investigation launched by the Bishop of Montreal turned up nothing but was quickly dismissed as a cover-up. It would take a full-scale investigation by a New York newspaper named William Leete Stone leading a team of Protestants to the convent to determine that, not only was there no secret tunnel, but it was unlikely that Maria had ever been there at all

This opened the floodgates to claims and counterclaims. Maria's supporters accused the Church and the convent of secretly destroying all evidence that might have confirmed Maria's story. Her critics (and there were an increasing number of them), used the inconsistencies in her account to discredit her. According to later sources (including her mother), Maria had sustained brain damage at the age of seven after "ramming a slate pencil into her head".  As a result, she was given to telling "whoppers" thereafter. Not only was she never a nun, she was not even Catholic and had a history of telling colourful tales of abuse to anyone who would listen. Apparently, during the period when she had supposedly been in the convent, she had actually been incarcerated in a Magdelene asylum following an arrest for prostitution. It was actually her legal guardian (and lover), William Hoyt who had come up with most of the details that found their way into print (not to mention pocketing most of the profits from the book). Maria had actually contributed little to the book itself as it had been largely ghost-written by a local publisher. Despite the revelations, Maria would publish a sequel titled Further Disclosures which also sold well. She had left Hoyt by that time and had taken up with another "protector" who soon left her after pocketing most of the sequel's profits.

Following the birth of a second illegitimate child in 1838, her few remaining supporters abandoned her and Maria lived the last years of her life in alcoholic poverty. She died in a New York debtor's prison in 1849 after being arrested for picking the pocket of a man with whom she had been cohabiting. Despite her sad end, her book has gone in and out of print and many anti-Catholic sources still cite her revelations as true.

What to make of Maria Monk? While there is evidence that her childhood brain damage had left her with a case of pseudologia fantastica, she was also clearly exploited by the men in her life who cashed in on her tales and abandoned her when she stopped being of use to them. Does that make her a victim or not? You be the judge.

After Disaster Strikes

While the 11 September 2001 terrorist attacks resulted in thousands of deaths and injuries, some injuries remain undiagnosed. The May 2008 issue of Prehospital and Disaster Medicine presents a research study examining incidence of traumatic brain injuries among persons hospitalized in New York City following the 11 September 2001 attacks. Using medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the attacks, individuals diagnosed with traumatic brain injuries (TBI) were identified using diagnosis codes from the International Classification of Diseases (9th Revision). Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons suspected of having an undiagnosed TBI were subsequently contacted and informed of the diagnosis of potential undetected injury.

The results indicate that, of the 282 records that were examined, fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the total). The leading cause of TBI was being hit by falling debris (22 cases) and one-third of the TBIs (13 cases) occurred among rescue workers. More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they were currently experiencing symptoms consistent with a TBI. The researchers conclude that not all cases of traumatic brain injury among hospitalized survivors of the 2001 attacks were identified at the time of acute injury care. Many individuals with undiagnosed cases were found to experience problems due to lack of effective diagnosis and treatment. The authors recommend additional clinical surveys be provided in-hospital for hospitalized survivors of mass-casualty incidents to help improve pre-discharge TBI diagnosis and refer patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers also needs to be re-evaluated.

Click here for the abstract.

Does Child Abuse Affect Brain Development?

I was just attending the annual conference of the Association for the Treatment of Sexual Abusers that was held in San Diego this year. It was a stimulating experience with talks and workshops by some of the leading clinicians and researchers in the field. One of the high points of the conference was a presentation by Dr. Martin Teicher, Associate Professor at Harvard Medical School and director of the Clinical Biopsychiatry Research Program at McLean Hospital in Belmont, Massachusetts. The focus of Dr. Teicher's presentation was on the neurobiological affects of different types of stress on the developing brain, especially in terms of the short and long-term impact of child physical and sexual abuse on brain development. In particular, that early childhood maltreatment acts as a severe stressor that can produce various physiogical and hormonal reactions that leads to lasting alterations in patterns of brain development which, in turn, can manifest as different psychiatric disorders. Early stress can program the body's "fight or flight" systems to react more adversely to later stressors. There is also evidence for different periods during development when different regions of the brain are especially affected by early stress. Therefore, it isn't just the nature of the abuse but at when the abuse happens that can affect later development. Early neglect can also be as debilitating as physical or sexual abuse (a point that I have discussed before).

There also appear to be different abuse-related syndromes associated with particular ages of abuse and specific regional brain changes. Posttraumatic Stress Disorder, Major Depression, Borderline Personality Disorder, Impulse Disorders and aggression may be the result of abuse that only emerges at a much later stage of brain development (or even in adulthood). Even verbal abuse can impact later emotional and social development. Dr. Teicher concluded the presentation by arguing that society reaps what it sows in how children are nurtured. Early abuse can mold the brain to be more irritable, impulsive, and hypervigilant. He states that "maltreatment is a chisel that shapes a brain to contend with anticipated strife but at the cost of deep, enduring wounds. Early childhood stress isn't something you "get over". It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence which often leads victims of abuse to become abusers".

Click here for the complete presentation.

Wrestler's Brain Showed Signs of Dementia

An examination of the brain of wrestler Chris Benoit revealed evidence of extensive neurological damage at the time of his death.  Benoit, a well-known professional wrestler, killed himself in June of this year after murdering his wife and child.  At the request of Benoit's father, Dr, Julian Bailes, head of neurosurgery at a top American university, examined the brain and concluded that the extensive damage resembled what would be found in "an 85-year-old Alzheimer's patient's brain".  Stating on American TV that the damage was "striking and maybe shocking", Dr. Bailes added that  "we think we have great anatomical damage here from previous trauma. Whether it had a psychiatric or behavioral expression, we certainly think that's most likely."

While the most likely cause of the damage is from the numerous concussions that Benoit sustained during his wrestling career in Japan and America, he was also known to be a heavy steroid user.  Dr Bailes added: "Our research has shown that three major concussions may be the threshold that serious later consequences may occur."

Michael Benoit, father of Chris, commented on the findings by stating that  "The person that did this is not the man we know and love. Now the findings have come out and I've had the opportunity to talk to the doctors, we certainly have an understanding of what could have contributed to the tragedy that took place that day. "

It still remains unclear why dementia pugilistica (also known as punch-drunk syndrome) occurs in athletes who have sustained multiple concussions.  Potential contributing factors include loss of neurons, brain tissue scarring, diffuse axonal injury, and buildup of senile plaques.  In terms of etiology, it strongly resembles Alzheimer's disease in many aspects.  While most commonly associated with professional boxers such as Muhammad Ali and Sugar Ray Robinson, athletes in other sports including football and hockey have also been diagnosed.

Click here for more information.