Head injuries are extremely common and in my practice (I am a Psychiatrist), I ask about them routinely. Many of us forget the head injuries we sustain, especially if they have happened several years ago. Most of us have played some games in childhood that requires jumping, falling or hitting a ball with our heads, as in soccer. These injuries can have long-term consequences. There are ten vital things everyone should know about head injuries.
- The brain is a very soft organ housed in a very hard skull. A narrow space of a few millimeters exists between the skull and the brain. When a hard object collides with the front or the side of the skull, the brain wobbles within this space, and if the blow is severe enough, the brain can sustain an injury. Additionally, the interior of the skull is jagged with sharp, bony involutions. Violent contact between them and the brain can cause damage to the soft tissue of the brain.
There are two basic kinds of brain injuries:
- Sustained and repeated injury, as suffered by boxers or footballers.
- One-time concussive injuries, as in accidents with or without loss of consciousness.
- Although this is not a definite rule, the sustained, repeated injuries usually damage the interior and deeper parts of the brain (like the Basal Ganglia) and the one-time, concussive injuries usually involve the surface of the brain.
- Deeper injuries cause serious problems such as Parkinsonism due to damage of the Basal Ganglia (think of the boxer Muhammad Ali), slurred speech and greater incidence of late-life dementia.
- Superficial injuries can lead to problems resembling ADD, such as poor concentration and attention, low motivation, inability to think, personality changes, depression, disorganization, sloppiness, impulsivity and anger episodes that can sometimes lead to violence (I usually see the second kind in my practice)
- Why do head injuries cause these problems? The brain is more likely to move in a forward-backward direction after an impact, and most injuries involve the front of the skull. This mostly leads to damage of the Frontal lobe. This part of the brain is responsible for focus, concentration, impulse-control, mood control, motivation and personality. The Frontal lobe controls our underlying emotions, rage and anxiety. When it does not function properly, we tend to experience these symptoms with greater frequency.
- These problems look and sound similar to ADD (Attention deficit disorder). Very often, the two occur together. Folks with ADD are more likely to be reckless, because they seek thrills in order to keep their Frontal lobes active. They indulge in risky sports, such as skateboarding, car-racing and even street-fighting. This leads to a very common co-occurrence of ADD with head injuries. However, head injuries can also produce these symptoms without any pre-existing ADD.
What can we do about this problem? Addressing the issue requires two steps:
- Recognition and diagnosis
Recognition occurs in two steps:
- A detailed history: I commonly ask patients several questions about the possibility of head injuries, even if their first response is negative. Most folks who deny having any head injury will later confirm that they were in a fist fight at age sixteen, or that they fell and hit their head while playing basketball ten years ago. I then try to establish possible connections between the onset of their emotional problems and the head injury. I have found that in most cases, such a connection indeed exists.
- The other aspect of diagnosis is imaging. Most of these brain injuries are ‘shearing injuries’. This means that the traumatic impact causes damage of the underlying white matter in the brain. Therefore, imaging techniques like CT scans and MRIs, which look at only the structure of the brain, usually do not pick them up unless the injury is extensive. Identification of these injuries requires a ‘functional’ image. I use Brain SPECT (Single Positron Emission Computed Tomography) imaging for this purpose.
Once the presence of a head injury is established, a TREATMENT PLAN can be formulated.
- In many cases, the cognitive problems such as poor focus and attention, low motivation and mental fogginess respond to the same medications that are effective for ADD.
- Stimulants such as Adderall and Concerta can provide almost immediate and dramatic relief. However, one has to be careful if the head injury has also resulted in severe anger, because stimulants can increase anger episodes.
- The Physician also has to be very careful to ask about the occurrence of seizures after the head injury, because stimulants can sometimes worsen a seizure disorder.
- Both the above conditions need to be first addressed with a mood stabilizer (or anticonvulsant) such as Depakote, Trileptal or Tegretol. Then, after the anger episodes are well-controlled, a stimulant can be added.
- A proper diet with adequate protein content and aerobic exercise can also improve blood flow to the Frontal lobe. Antioxidants such as n-acetylcysteine, CoQ and L-methylfolate can reduce further brain injury and improve outcomes.
So avoid those head injuries by wearing your helmets and stay away from violent and sports. And remember, unlike most other objects, the human brain has very low capacity for regeneration after significant injury.
Shahid Insaf M.D