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.

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

Traumatic brain injuries are a subset of acquired brain injures, which are not the result of trauma, but occur after birth: hypoxic brain injuries (lack of oxygen to the brain), and anoxic brain injuries (no oxygen to the brain).

In a diffuse axonal brain injury (a type of closed traumatic brain injury) the skull is not broken, but the brain is violently jarred and collides with the skull, causing tissue swelling. Since there is no opening to relieve the swelling, there is increased pressure in the brain, damaging neurons, the core cells of the nervous system. As a result, the communication network between neurons is impaired (think of a downed cable or telephone wire), and basic functions like speech, and  breathing might be affected.

A concussion is caused from direct impact to the head by an object, or sudden movement or momentum from shaking, like in whiplash. Neurons stretch and blood vessels tear, which can cause contusions – bruises on the brain. The individual may or may not lose consciousness. Shaken Baby Syndrome, also known as Abusive Head Trauma and Shaken Impact Syndrome – is a form of whiplash where the aggressor vigorously shakes the baby. Most of these cases occur when babies are between 6 and 8 weeks old, since that is when they cry the most. The trauma may cause them to experience vomiting, seizures, irritability, and poor feeding.

In an open brain injury, the skull is fractured. If it’s pierced, say, from a gunshot or knife, the skull splinters, and fragments can hit brain tissue, causing further tissue damage (a penetrating injury). Even though cell damage can occur in an open injury, there is less chance of brain swelling and therefore increased pressure. That’s why doctors consider them less dangerous than closed head injuries. But, because there is an opening in the skull, bleeding into the brain can occur. And the individual is at high risk for infection, most commonly meningitis – an infection of the membranes surrounding the brain and spinal column.

Frontal lobe injuries affect the front part of the brain. The frontal lobe controls motor skills, thoughts, emotions,and personality. The left side of the lobe controls verbal communication, and the right side controls non-verbal communication – the arty side of our brains. The right lobe also plays a role in negative emotions, while the left lobe involves positive emotions. The area of the frontal lobe that is damaged will dictate how your emotions and personality are affected. Once a cautious person, you may now find yourself to be more impulsive.

So I suppose it shouldn’t come as a surprise that the brain is susceptible to injury. Weighing a slight 3.4 pounds, and encompassing more than 1 billion neurons with an infinite number of connections, the brain is a delicate mass of tissue floating in a fluid environment, much like a fetus in a uterus.

http://www.msktc.org/tbi/factsheets/Understanding-TBI/What-Happens-During-Injury-And-In-Early-Stages-Of-Recovery

http://www.braininjuryinstitute.org/Brain-Injury-Types/Open-Head-Injury.html

http://kidshealth.org/parent/medical/brain/shaken.html

Traumatic Brain Injuries 101 In the United States, 52,000 deaths occur each year from a traumatic brain injury (TBI), and 5.3 million people live with disabilities due to a TBI. But a TBI does not necessarily result from a major trauma, like skiing into a tree or plummeting off a roof. You can sustain a TBI from bumping your head on a kitchen cabinet door, or when you and your five year old smack foreheads while wrestling. Penetrating injuries – from a bullet, or other objects that enter the skull – can also cause TBI’s. But the most common causes are from auto accidents and falls.

TBIs range from mild to severe. Mild injuries – concussions – are the most common. Symptoms include confusion, irritability, nausea, fatigue, amnesia around the event, and loss of consciousness up to 30 minutes. But it’s possible to suffer a mild TBI and not lose consciousness. Also, being diagnosed with a mild TBI does not mean the consequences are mild, such as decreased concentration and attention, getting lost and confused, headaches, dizziness, depression, mood swings, sleep disturbances, and difficulty with balance. Many people experience these symptoms for years, which is what happened to me. I still suffer from poor concentration, depression, difficulty multi-tasking, planning and even judging distance. When driving, for instance, I have trouble thinking ahead (at least that’s what my husband tells me). But it’s true. My brain can’t process all the stimuli coming at me: other cars, beeping horns, bicycles, and joggers. It doesn’t have enough room to focus on getting in the left lane soon enough so I can take a left turn.

In moderate TBI’s, the individual loses consciousness from 30 minutes to 24 hours, and in severe TBIs, longer than 24 hours. Symptoms are worse for people diagnosed with moderate to severe TBIs. They tend to exhibit obvious behavioral issues like aggression, and suffer greater physical impairments, like decreased ability to smell (anosmia), ringing in the ears (tinnitus), paralysis, and slurred speech.

But the challenge is in diagnosing TBIs, especially mild ones (like I said earlier, mild from a trauma perspective, not from a consequence perspective. I’ll address the nuances of this in a future post). My TBI was diagnosed in 2006, three years after I sustained the injury. During the immediate hours after the accident, the doctors where concerned with my other injuries – stopping the bleeding from my ruptured spleen and stabilizing my fractured pelvis. So I struggled in the workplace for two years, and at home, blaming my symptoms wholly on PTSD.

http://www.northeastern.edu/nutraumaticbraininjury/consequences-of-tbi/