Because traumatic brain injuries are the result of a trauma, it’s common for TBI survivors to also suffer from PTSD. But differentiating the cause of symptoms can be challenging. Depression, anxiety, cognitive difficulties, and fatigue are common to both. But PTSD is a mental condition, whereas TBI is a neurological condition.

In TBIs, individuals may experience retrograde amnesia: memory loss of events – usually recent ones – that occurred prior to the injury. Before the elderly driver ran into me at the Santa Monica Farmers’ Market, I recall holding a peach, then nothing else, until I woke up in the emergency room more than an hour later. Even then, my memory is spotty. In PTSD, people are haunted by intrusive thoughts and memories of the trauma. Even though I do not remember the accident, I have been haunted by thoughts of the gruesome scene. Imagination is powerful.

Fatigue is a hallmark feature of TBIs. The brain tires easily, and therefore must work harder to process information. When I’m exposed to too much stimuli – chatter, whining children, and bright lights – I feel as if my head is stuffed with cotton. In PTSD, hyper-vigilance keeps people awake (see Post-Traumatic Stress Disorder: A Re-Wired Brain). In anticipation of nightmares, they may be afraid to fall asleep. So my TBI causes my brain to work over-time, and the nightmares I still experience startle me awake, keep me awake, draining what little fuel is remaining in my brain.

In TBIs, there may be damage to the frontal lobe – the area of the brain that controls emotions and personality, so emotional swings are not uncommon. In the few years after my injury, I found that I was more irritable and cried for no apparent reason: when washing the dishes, or standing in line at the bank. Emotional numbness is more common in PTSD. People may no longer be interested activities they once enjoyed. I recall days when it took a Herculean effort just to get out of bed and dressed for the day – sometimes it still does.

About fifty percent of those with TBIs suffer from depression. Compare that to the approximately seven percent among the general adult population. Depression is also common in those with PTSD, particularly war veterans, but since they want to avoid the stigma of mental illness, they hesitate to report symptoms and refrain from talking about the trauma at all.

Since PTSD is an anxiety disorder it’s natural for people to experience heightened stress, especially when reminded of the trauma. But in TBIs, people appear unmotivated when the truth is they lack the ability to initiate activities. I may seem lazy because I don’t cook and rarely food shop, but that’s because my TBI presents with the inability to make decisions – which kind of pasta to buy, or what to cook for dinner.

Given the overlapping of symptoms between a TBI and PTSD, neither one fits squarely on its own shelf. But I suppose that’s the way it goes with most things.

http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml

http://www.brainlinemilitary.org/content/2013/03/tbi-and-ptsd-navigating-the-perfect-storm_pageall.html

Ten months before I suffered my traumatic brain injury, I started learning how to play the fiddle. But, distracted by pain, fatigue and medical appointments during the first months of my recovery, I thought I’d never play it again. And the few times I tried, the notes sounded either too flat or too sharp. I’d put it back in it’s case, then set it in the corner of the living room, somber and angry at the same time.

Through the persistent support of friends, I eventually practiced again, every day. I started practicing for ten minutes at a time, but quickly increased my sessions to twenty minutes, a half hour, then an hour. I needed the music – immersing myself in the sounds of each note and the melodic phrases of Irish jigs and reels helped me to focus. But I did not know what effect playing the fiddle, or learning any instrument, had on the brains of TBI survivors.

Scientists used to believe that changes in the brain could occur up until only childhood. But modern research has shown that the brain can create new pathways and alter existing damaged ones to form new memories and learn new information. The process, called neuroplasticity (brain remapping) can take months, or even years. But neuroplasticity can also occur through active learning, called structural plasticity. Researchers have found, through music training, areas of the brain involved in cognition such as memory, speech, attention, and language are strengthened. For instance, children who are musically trained have stronger vocabularies and reading skills than those who are not musically trained. Similar patterns have been observed in adults.

So I continue to push the bow across the fiddle’s strings. I call these sessions my brain workout.

http://neurosciencenews.com/neuroscience-music-enchances-learning-neuroplasticity/

Neuropsychologists are not medical physicians; they are psychologists who study the relationship between behavior and the brain. They first interview the individual: work and medical history, family dynamics, and school performance. The neuropsychologist gathers this information in order to compare level of functioning prior to a traumatic brain injury with post-injury functioning. The testing covers a broad range of areas: concentration, attention span, basic and abstract thinking, memory, mathematical reasoning, motor skills, problem-solving skills, judgment, and emotional character.

In May 2006, when I believed there had to be more than PTSD to blame for my difficulties in the workplace, I saw a neuropsychologist. I spent eight hours filling out self-evaluation forms and undergoing testing. Separately, my husband and I scored (one being the best, ten the worst) my level of irritability and depression, and my ability to remember things, concentrate, multitask, recall words, and think quickly. Our scores were nearly identical, with most of them ranging between five and eight. I spent the remainder of the day filling in dots on questionnaires, naming faces in photos, sticking pegs in tiny holes in less than fifty seconds, drawing figures from memory, naming as many items as I could think of that started with the letter T in less than one minute.

A few weeks later, the results came in the mail: the tests suggested I had sustained a traumatic brain injury when I was hit by a car three years earlier.

Finally, I had answers as to why I had trouble following conversations, learning new information, or performing most tasks in a timely manner. Finally, I had a reason as to why I could not retrieve the word from my brain when the neuropsychologist asked me to name the photo of two vertically connected glass bulbs with sand trickling from the top bulb to the bottom bulb.

Hourglass.

Emblematic of the passage of time, the hourglass also marks new beginnings.

When writing about a past event in the present tense, how does the author manage to control the narrative? In other words, how do readers know when the author is speaking from the present of the past versus the present of the now? It is usually much later when we are able to reflect mindfully on a past event, say, pose rhetorical questions and conjure answers about what happened. So how does the author insert reflection, or what Sue William Silverman calls the voice of experience – the metaphors for instance – in to the present tense telling of a past event?

In Jyl Felman’s memoir, Cravings, she predominately writes in the present tense with brief shifts into the past tense. She employs transitional phrases or words to indicate place and time:

“Every February until she’s too sick.”

“When we are growing up.”

“Ten years later.”

“Right before their fortieth wedding anniversary (14, 15, 18, 26).”

This is how Felman controls the overall architecture of the narrative, and the shifts between the actual now, the past, and the future. For the most part, Felman doesn’t fully step out of the present telling of the past and reflect. Rather, the reflective moments are embedded within the scenes of present tense narration. For example, in the chapter, Hyperventilation, she shows us, through scene, how her mother washes her mouth out with soap for swearing, and how she makes herself hyperventilate and needs to go to the hospital. It’s almost like a listing of events – this happened, then this happened. But intertwined is the voice of experience – metaphorical phrases – such as her descriptions of the process of passing out and how she feels like she’s suffocating. In effect, Felman is saying she needs time out from her family. We also hear the reflective voice in her telling of how she realizes the dysfunction in her family, and that she’s unhappy but no one notices (81-90). Foods, her mother’s recipes, and Jewish tradition – threads throughout the narrative – are also metaphors – the voice of experience – in the book. Felman successfully floats these within the present telling of the past.

She does revert to past tense when telling us more about her sister Judy: her anorexia, stealing, etc. It is in these passages where we gain more insight into the family dynamics – there seems to be a greater sense of interiority here. When Felman returns to the present telling of the past, again, it’s a listing of events. There’s a fast paced feeling about it – no lingering. The present tense telling has a way of building tension. There’s almost a rhythmic quality to the way Felman narrates about Judy in those pages: Judy is lost, her father finds her, Judy’s in Seattle, she’s married then divorced, and so on. At the end of the memoir, Felman does reflect from the real present into past moments. But, again, it is the precise phrases that help us know where we are: “It’s two years since she died, only the memories live in my body (187, 188).”

Here is a list of other memoirs written in the present tense: The Kiss by Kathryn Harrison Another Bullshit Night in Suck City by Nick Flynn, The Accidental Buddhist by Dinty W. Moore. Blackbird by Jennifer Lauck, When Katie Wakes by Connie Mayfowler, Because I Remember Terror Father, I Remember You by Sue William Silverman, Love Sick by Sue William Silverman

Citations: Felman, Jyl Lynn. Cravings: a Sensual Memoir. Boston: Beacon, 1997. Print.

Physicians rely on various tests to diagnosis a TBI. The Glascow Coma Scale (GCS) measures three areas: ability to open eyes spontaneously, to speech, pain, or not at all. The ability to speak: is the patient confused, unable to speak coherently, or not able to speak at all? The ability to move: does the patient respond appropriately to painful stimuli? Are there abnormal movements?

Each area is scored. The best possible score is fifteen. Thirteen or greater indicates a mild TBI. Nine through 12 suggests a moderate TBI, and 8 or lower is likely a severe TBI. Since the GCS scores the initial injury, it is not a predictor of the patient’s recovery and functional ability. If a 13 is assigned to the initial injury, the patient may still exhibit long-term deficits like difficulty processing new information. My GCS score at the time of my injury occurred was fourteen.

Symptoms are also helpful in diagnosing a TBI, such as clear fluid (spinal fluid) draining from the ears or nose, irregular breathing, dilated pupils, coma, paralysis, numbness or tingling, vomiting, and loss of bowel and bladder control.

In TBI’s there may be brain swelling and bleeding, which can be seen on Computed Tomography (CT scan) or magnetic resonance imaging (MRI). CT scans are not as sensitive as MRI’s, but take less time to complete – the reason why they are taken in the acute phase of treatment. However, both techniques cannot detect torn neurons, or microscopic bleeding (see post: The Brain: A Delicate 3.4 Pounds). For those who sustain neuron damage, but no swelling or significant bleeding, it’s difficult to diagnose a TBI. This was the case in my injury. It’s easier to diagnose patients who show obvious signs of a TBI (see symptoms above). But in those that do not, physicians must rely on subjective input from patients. That’s why many people go years before being diagnosed. If you have heard of TBI’s referred to as an “invisible injury,” now you know why.

http://www.biausa.org/brain-injury-diagnosis.htm http://www.nlm.nih.gov/medlineplus/tutorials/traumaticbraininjury/nr289102.pdf