Mild Traumatic Brain Injury--The "Missed" Diagnosis

The following article is a summary of one I found at the International Society of Neuronal Regulation website. For the full text, go to http://www.isnr.org/pubarea/mtbi.htm

Mild Traumatic Brain Injury--The "Missed" Diagnosis

by Joseph J. Horvat, Ph.D., Corpus Christi, Texas, and D. Corydon Hammond, Ph.D., ECNS, QEEG-D, BCIA-EEG, University of Utah School of Medicine.

Of all the psychological diagnoses available, it is our opinion that the one that is most commonly misunderstood and misdiagnosed is that of mild traumatic brain injury (MTBI). Mild traumatic brain injury, also called closed head injury or post-concussion syndrome, is a condition where an individual suffers a blow to the head and subsequently develops symptoms.

Although some research suggests that most MTBI symptoms will improve in three or four months, other research shows that in many cases the symptoms will remain for years following even a mild concussion, whiplash, or blow to the head. The inconsistent results are due to varying definitions of MTBI, how the data is gathered, what constitutes 'real' symptoms, and perhaps most importantly, the "human factor" – the beliefs and biases of the various researchers.

It can be hard for some people to believe that even a mild blow can be the cause of so many symptoms. In an emergency room, physicians are primarily screening for serious brain injuries, and mild brain injuries are generally not noticed. When the patient has been told that they seem fine, but later develop symptoms, other people, the patient themselves, and insurance companies may not consider the symptoms to be from the mild head injury. In addition, the symptoms of MTBI are not specific to only a head injury. Virtually every symptom that can be associated with MTBI, as seen in the lengthy list below, can be due to other disorders. Therefore, if after hitting your head you have been told that you are okay, and the symptoms you notice later are not necessarily associated in your mind with a blow to the head, you may not connect the symptoms with a brain injury. The end result is that sometimes months or even years after a whiplash or blow to the head, MTBI is often not even considered as a possible cause of symptoms. The correct diagnosis is, therefore, “missed” and the person may not be taken seriously, be sent to psychotherapy, or even be thought to be fabricating symptoms.

Listed below are some of the symptoms that are most commonly associated with a mild head injury. Of course you do not need to have all of the symptoms that are listed for a diagnosis of MTBI. Symptoms vary depending on the severity of injury and the parts of the brain that are injured. You will want to determine, has there been an increase in symptoms like these following a whiplash, concussion, or mild head injury?

Common Symptoms Associated With MTBI

1. Difficulty figuring out how to do new things.
2. Being disorganized in your approach to problems.
3. Having difficulty completing activities in a reasonable amount of time.
4. Being slow to learn new things.
5. Becoming easily frustrated, irritable, and having outbursts of anger or rage.
6. Problems with word finding (remembering the right word to say).
7. Hypersensitivity to light or sound.
8. Problems with concentration and being easily distracted.
9. Spacing out and losing your train of thought.
10. Problems with short-term memory.
11. Becoming more forgetful.
12. Increased frequency of headaches.
13. Increased impulsiveness, impatience, risk taking, rudeness, or social impropriety.
14. Fatigue
15. Fibromyalgia type symptoms—mental fogginess, difficulties getting restorative sleep, diverse pain.
16. Problems with physical balance, dizziness, tremor, clumsiness, or incontinence.
17. Having difficulty in being able to be flexible in changing plans or switching from one activity to another.
18. Problems reading letters and words.
19. Difficulty in understanding what others are saying.
20. Confusion in telling right from left, or with puzzles.
21. Getting lost easily.
22. Being fidgety and having difficulty remaining seated.
23. Going from one activity to another without finishing tasks or projects.
24. Decreased libido.
25. Difficulty with speech, language, or math skills.
26. Seizures.
27. Sensory problems: with vision, hearing, taste, smell, sensation.
28. Emotional difficulties (depression, fear, nightmares).

Following a concussion or head injury, emergency room physicians commonly order CAT scans or MRI’s to rule out serious injuries. Unfortunately, these scans usually don’t reveal mild to moderate damage because they are examining only the structure of the brain and not how the brain is functioning. Therefore, as we have indicated, the subsequent MTBI symptoms may not be taken seriously or be attributed to the head injury. However, there are other tests such as the quantitative EEG (QEEG), PET, or SPECT scans that evaluate how the brain is functioning in comparison with normative databases.

In our clinical experience, neurofeedback training often proves extremely helpful in providing further rehabilitation of brain injury as well as stroke symptoms, even many years after the injury has occurred.

For more articles on neurofeedback and brain injury, go to http://www.snr-jnt.org/topics/tbi/eegbiofeedback.htm

Symptoms of head injury reversed

Mario was a family man who was close to retirement. His life changed dramatically when a car crashed into him two years prior and he was knocked unconsicous for a few minutes and suffered a slight concussion. While he did not injure any other part of his body significantly, he began to notice mental changes. He began to recognize a loss of short-term memory, couldn't find words, and was frus­trated easily. He started hating his job and complained a lot about problems with their children and grandchildren, which he never did before. His wife noted that he was frighteningly forgetful, had a string of new automobile accidents, neglected all aspects of his health, and was constantly tired. She attributed these symptoms to depression, as he had been taking an anti-depressant medication for the previous 5 years.

Neither Mario, his wife, nor his doctors attributed his new difficulties to the accident. Mario simply thought he was "go­ing down hill due to old age”. Since the accident, he had become very somber and nothing was funny. He would put on his pajamas at five in the evening, his wife would bring him his dinner, and then he would sleep. Later in the evening he would wake in a state of disorientation and begin to dress, without being able to articulate what he was thinking or planning.

Mario's wife finally had enough and insisted he seek treatment. Mario reluctantly called me for an appointment. He was relieved to find that there was help for his condition, although he was skeptical at first. He responded rapidly to neurofeedback using the Neuropathways unit.

One of the first changes that his wife noticed as a result of NFB was that he began to laugh out loud. At the end of 8 sessions, Mario's sense of humor was fully restored. Mario began to enoy his family again and started engaging in projects with his grandchildren. He started taking a walk every evening with Ruby and she expressed joy that she was not alone in a marriage any more, but rather had a fully engaged companion.

Before, Mario had periods of rage with little provocation, which were intensely upsetting to his wife. Although he was never violent, he would scream, yell, stomp around, throw tools, and was almost completely out of control. After NFB training, his wife reported he never lost his temper anymore, never screamed, or stomped around. Mario instead became very considerate and attentive to others.

Before, he had severe difficulties getting organized and couldn't concentrate on necessary tasks. He struggled to keep up with a bare minimum of work on his house and on his job. Mario struggled to complete what he now regards as simple re­ports, often having to stay up all night to get the job done. After NFB, he now finds that this same volume of work is not at all problematic.

Before, he had become "disoriented and aimless". He and his wife worried if these symptoms could be attributed to early Alzheimer's disease. He found himself excessively daydream­ing and often had extreme lethargy. At his work, he would sometimes lose track of what he was doing, and had difficulty sustaining attention. His memory was poor. He had difficulty getting organized. As a result, his job was at risk. Although he had worked a lifetime, had a strong work ethic and excellent performance, he was now unable to complete his responsibilities and had been written up for poor work performance. After NFB training none of these behaviors were problematic. His energy improved, he could concentrate again, and his work performance returned to its former level. He stopped hating his job and stopped focusing on the day he could retire.

Before, he was an extreme worrier. He became very upset when things did not go his way or were out of place. He had the tendency to say “no" first before considering the possibilities, and would predict negative out­comes. He rated his depression as unremitting. Following NFB training, all these problems were dramatically diminished. His depression was completely gone.

Mario and his physicians appear to have mistakenly attributed symptoms of unrecognized brain injury and depression to age-related cognitive decline. Following 8 neurofeedback trainings, Mario's difficulties with word-finding, memory, concentration, attention, and organization improved dramatically. He had very significant elevation in mood and in his capacities for self-control, fun, humor, and his ability to fully engage in his relationships were restored. Mario became much less negative and irritable. His explosive outbursts disappeared and his relationships with his wife, family, and work were restored to his previous level of functioning.