To understand what happens to mood, to attention and to various body systems when the brain has been injured, it’s important to understand how the brain works in the first place, says Sandeep Vaishnavi, director of the Neuropsychiatric Clinic at Carolina Partners in Raleigh and a neuropsychiatrist with Duke University Medical Center.
Vaishnavi and Vani Rao of Johns Hopkins University are co-authors of “The Traumatized Brain: A Family Guide to Understanding Mood, Memory, and Behavior after Brain Injury.” Appropriately, the book opens with a primer on the circuitry of the mind itself – circuits that, when damaged, can have wide-ranging repercussions.
“We still have this concept that mental health and physical health are two separate things,” Vaishnavi explains. Today, this is called Descartes’ error, a dubious honor for the French philosopher typically credited with the notion of mind/body duality. “Over time, in my opinion, we’ll understand that mental health and physical health are really integrated, and we’ll treat them in a much more integrated manner.”
It’s an important awareness to have when dealing with traumatic brain injury (TBI): changes in mood, attention and altered sleep habits – things typically thought of as psychiatric symptoms – can manifest well after the initial physical injury. And for all the increasing awareness of TBI in combat veterans and football players, including the upcoming Will Smith film “Concussion,” Vaishnavi wasn’t aware of any book by medical experts focusing on the neuropsychiatric aspects of TBI. Sure, there were medical texts and books written by TBI survivors, but nothing like this.
We caught up with Vaishnavi to talk about “The Traumatized Brain.”
Q: What leads to the delay between the injury and the symptoms?
A: When a person has a traumatic brain injury, especially if it’s more moderate or severe, the focus is on the more acute aspects; the doctors are working on you to make sure you survive. After that, there are things that can occur in the early recovery process. People can become delirious and seizures can develop. A lot of the other things we see later on, a lot of the cognitive issues we emphasize in “The Traumatized Brain,” we don’t see that early on because there are other things that overwhelm the system.
Q: I’ve read about combat veterans who were near explosions and the effects of the concussive blasts. Is that also TBI?
A: Absolutely. There can be different types of TBIs. There can be more direct impacts, like there can be shrapnel from an IED that can hit the head. There are actually pressure changes that can occur with this kind of blast. Those pressure changes are also a type of TBI.
Q: Can you explain what causes the mood changes?
A: Things like personality changes, aggression, agitation, those sorts of thing – a lot of times those are related to damage to the frontal lobes and temporal lobes. Those particular parts of the brain are particularly vulnerable to damage because the skull around those parts of the brain tends to have bony ridges that are kind of sharp. When there is an impact to the head, the skull moves a little bit, but the brain moves a lot more, and the bony areas can shear into the brain, especially the frontal lobes and the temporal lobes. Those are the areas that are really important in terms of neuropsychiatric symptoms.
Q: What can people expect in terms of recovery?
A: This is dependent on the level of the injury. Most people who have a single mild traumatic brain injury or concussion do recover. There are a small percentage of people where it takes a lot longer, and there’s an even smaller percentage of people who do not recover.
That may be a different story for repetitive mild traumatic brain injury. If you have multiple concussions, they may accumulate over time, so recovery may not occur. That’s one of the things that people are looking at in terms of pathological studies with NFL players and others. There’s this notion of chronic traumatic encephalopathy, or CPE, which is basically where there are neurodegenerative brain changes that occur after multiple concussions.
In terms of moderate to severe traumatic brain injury, there’s a lot of variability. The more severe the brain injury is, the more difficult it is to get back to the previous baseline.
Q: What are some current areas of research?
A: One of the most exciting areas right now is in terms of assessment: How do we capture and diagnose traumatic brain injury quickly and appropriately? It is not always very clear, especially on the milder end. People may ignore it; they might not even realize that it is a brain injury. The way we clinically assess it is if there is gazing or confusion, even if it’s momentary, then that’s a traumatic brain injury and we need to take that seriously. Then again, that’s a clinical diagnosis. We’d love to have a more objective measure. There are some studies out that have advocated for certain biomarkers for assessment of traumatic brain injury.
On the treatment end, there are new technologies that may be relevant. For example, there are studies right now with transcranial magnetic stimulation, or TMS. That’s basically using repetitive magnetic pulses to improve certain symptoms. That may potentially help with things like depression associated with traumatic brain injury, and perhaps other symptoms.
It’s an exciting time to be in the field right now, because we really understand a lot more about the brain and the circuitry of the brain. Once we understand the circuitry we can do something about it.