Running head: Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI)

Gregory Cordes
General Psychology
PSY7310 Physiological Psychology
Winter 2009
jgcordes@comcast.net

Abstract
This paper will discuss the nature of Traumatic Brain Injury (TBI), the scope of
the disorder, the types of TBI, and how psychologists can divide these types into
2 classes. In addition, this paper will discuss the cognitive, emotional, and
physiological consequences of TBI in the context of the type and class. There
will be some discussion on detection of TBI, early determination, first aid, and
future research and work, as well as the developmental variables.
Traumatic Brain Injury (TBI)
Introduction
What is TBI?
Traumatic Brain Injury (TBI) is a physical insult to the brain as a result of an
external physical force which produces an altered or diminished state of
consciousness (Brain Injury Association of New Jersey, 2008). The consequences of
TBI are typically an impairment of physical or cognitive abilities and may result
in disturbance of emotional and behavioral functioning. The cognitive
consequences of TBI include reduced ability to process information, organizational
problems, trouble concentrating, poor judgment, memory loss, and difficulty
starting activities. The physical consequences of TBI include muscle spasticity,
seizures, headaches, fatigue, and balance problems. An observer may expect to see
mood swings, depression, impulsivity, anxiety, and agitation as the emotional
consequences of TBI (BIANJ, 2008). TBI has 2 cousins that mimic some symptoms of
TBI, but are categorically different.
While the symptoms may be similar, observers should not confuse TBI with Acquired
Brain Injury (ABI) as a result of anoxia, aneurysms, encephalitis, stroke,
metabolic disorders, and meningitis or brain tumors (BIANJ, 2008). Mild Brain
Injury usually comes in the form of a mild concussion (BIANJ, n.d.). In sports,
concussion is the most frequent cause of brain injury, loss of consciousness is
not necessary for all concussions, people are a greater risk with each successive
concussion, and multiple concussions may result in a life time of consequences
(BIANJ, n.d.). The incidence of TBI is enormous.
In the United States, more than 1.4 million people sustain TBI annually, only a
sixth seeks help (BIANJ, 2008). This paper will discuss the significance of the
1.4 million victims later on. More than 50,000 people die annually from a TBI
related injury. Approximately 80,000 to 90,000 experience a long term disability
after receiving a TBI. In fact, more people sustain TBIs than breast cancer,
spinal cord injury, multiple sclerosis, and HIV/AIDS combined. Many times,
healthcare professions do not attribute behavioral issues, physical impairment,
and cognitive deficits to TBI. Public recognition of TBI is low, despite the
large number of injuries, mental healthcare professionals call it "the silent
epidemic" (BIANJ, 2008). There are several leading causes of TBI.
The American population sustains 28% of TBIs in falls, 20% to motor vehicle
accidents, 19% in struck by events, and 11% in assaults (Brain Injury Association
of America, 2006). The majority of military TBIs are a result of blast injury.
This paper will discuss blast injury later in the paper. The Centers for Disease
Control estimate approximately 5.3 million Americans live with a TBI (BIAA, 2006).
This number may grossly underestimate the number of TBIs, with 1.4 TBIs a year
(BIANJ, 2008) - the actual numbers could be as high as 70 million over the last 50
years. Typically, males are 1.5 times more likely to sustain a TBI (BIAA, 2006).
Children ages 0 to 4 and young adults ages 15 to 19 are the highest at risk
groups. The group with the highest death rates for TBIs is African Americans.
Americans hospitalize 235,000 people each year for TBI, at a cost of 60 billion
dollars. Of this 235,000, 40% require outpatient assistance after release. The
most common service needs are problem solving and memory, emotional upsets and
managing stress, controlling temper, and job skill improvement (BIAA, 2006).
Discussion
What are the types of TBI?
Psychologists can map the types of TBI across several dimensions, against
the effected area, force of the blow, nature of the assault, general symptoms, and
the physical consequences of the shock (BIAA, n.d.). General symptoms of the TBI
may include loss of bladder and bowel control, tingling or body numbness, slurred
speech, difficulty swallowing and speaking, irrational and emotional responses,
thinking skills problems, ear ringing, confusion, headache, lethargy, and
vomiting. In addition, the victim may have increase blood pressure with slow
breathing. Other symptoms include slow pulse, paralysis, coma, respiratory
failure, blurred and double vision, inability to tolerate light, eye movement
loss, blindness, dilated eyes, lost consciousness, and spinal and intracranial
fluid loss (BIAA, n.d.). There are several categories in the nature of the
insult.
Diffused Axonal Injury (DAI) occurs when the brain cannot physically keep up with
the movement of the skull (BIAA, n.d.). Typically, the cause of a DAI is strong
rotational forces applied to the head as might occur in an automobile accident.
These rotational forces tend to stretch and tear nerve tissue across the brain.
When the brain's nerve tissue is torn, it interrupts the brain's ability to
communicate between its various structures and disturbs its chemical processes.
In addition, a DAI is likely to release brain chemicals creating additional
injury. DAI is especially dangerous because the inside of the skull is rough,
rotational shifting the skull, but not the brain is likely to cause widespread
lacerations across the surface of the brain. DAI causes widespread permanent
damage that can result in coma or death (BIAA, n.d.).
Another type of TBI is concussion (BIAA, n.d.). Concussion can come in many forms
including gun shot wounds, a violent shaking, whiplash, or head blow. It is the
most frequent type of TBI. Concussion can come in the form of an open or closed
head injury. The sudden impact of the concussion causes cranial nerves and blood
vessels to stretch. The stretching of blood vessels can cause them to tear
resulting in a blood clot that can be fatal. Brain bleeding, skull fracture, or
swelling may be present, and their need not be a loss of consciousness.
Interestingly, physicians cannot always detect concussion in a Computerized
Tomography (CT) (BIAA, n.d.). Contusion is another type of TBI.
A contusion is the result of a focal impact on the brain (BIAA, n.d.). The focal
impact results in a bruise and subsequent bleeding. In many cases, large
contusions require surgical removal. A coup - contrecoup injury is similar to
contusion. But, the force of the blow is strong enough to cause a contusion on
the opposite side of the brain. This is the result of the brain, which is
essentially floating in intracranial fluid, slamming against the opposite side of
the skull (BIAA, n.d.). Multiple assaults to the brain are another type of TBI.
Recurrent Traumatic Brain Injury (RTBI) or Second Impact Syndrome (SIS) occurs
when a TBI sustains a second TBI before the first TBI has healed (BIAA, n.d.).
This insult is likely to cause widespread damage and brain swelling and can cause
death quickly. Increased muscle tone, muscular spasms, unstable emotions,
difficulty learning and thinking as well as hallucinations are the long-term
effects symptomatic of SIS. Physicians and Psychologists can characterize
penetration injury as the contamination of the brain by a foreign object (BIAA,
n.d.).
A penetration injury such as a bullet wound or knife forces fragments of hair
boned and skin into the skull (BIAA, n.d.). A “through and through” TBI occurs
when an object penetrates and then exits the skull. This results in shearing,
stretching, rupture, and penetration injury. If the object is unable to penetrate
the skull, it will begin to ricochet causing additional damage. Of all causes of
TBI, firearms are the largest. Similar to DAI, is shaken baby syndrome (BIAA,
n.d.).
Mental health professionals characterize shaken baby syndrome as the violent
shaking of a young child or baby where whiplash like motion results in TBI (BIAA,
n.d.). In this scenario, the skull ruptures and bleeds as blood vessels are torn.
This causes brain tissue to swell and compress damaging the cells. Shaken baby
syndrome can result in a lifelong disability, seizures, death, and coma (BIAA,
n.d.). One of the last of these TBI types on this axis of the map is locked
syndrome.
While rare, locked in syndrome sufferers can only move their eyes, but they retain
their ability to think and remain conscious (BIAA, n.d.). Typically they use eye
blinking and vertical eye movements to communicate and manage environmental
controls (BIAA, n.d.). The final type on this axis is blast injury.
Blast injury occurs when a complex over-pressurized wave passes through the
cranium (Defense Veterans Brain Injury Center, n.d.). The brain essentially
floats in intracranial fluid, and fluid filled cavities are especially susceptible
to blast injury (Elsayed, 1997; Mayorga, 1997). Victims of blast injury
experience slower thinking, depression, irritability, sleep disturbances,
headaches, and decreased attention/concentration, and memory (DVBIC, n.d.). One
characteristic of a blast injury TBI are small voids filled with intracranial
fluid within structures in the brain that are normally solid (Glasser, 2007). One
explanation for these voids is cavitation.
Cavitation is a mechanical effect that when a solid object moves through a liquid
medium at a high speed the fluid is unable to move out of the way fast enough
creating tiny vacuums behind the trailing edge of the solid object. An observer
can see this when the blade of a propeller on a boat turns and produces
characteristic voids that appear like bubbles. Of all TBIs, blast injury is the
most aggressive because the assault comes at about the speed of sound. It may be
possible that the speed of the shock produces cavitation in the brain as it passes
through nerve tissue and tearing it, then allowing low viscosity intracranial
fluid to fill the cavitation before the high viscosity nerve tissue can fill a
void. Another axis of TBI is open and closed wound.
Open head injuries occur when the skull is penetrated. The brain may swell, but
because it is no longer contained may result in squeezing nerve tissue. Open head
injuries are more likely to be penetration injuries, where a foreign object lodges
its self in brain tissue. Without the protection of the scalp and skull, the
victim’s brain is subject to infection. On the other hand, with a closed head
injury the brain may still swell, but was no place to expand, an intracranial
increase of pressure on the brain tissues results in further damage. In an
attempt to relieve pressure, brain tissue may attempt to force its way through the
eye sockets resulting in pressure on the optic nerve.
Whole Brain versus Localized Injury
Up to now, this paper has discussed the types of TBI from the perspective of a
physical insult to the brain. It is possible to divide these insults into two
classes, whole brain and local. Whole brain insults would include DAI, shaken
baby syndrome, blast, and concussion because damage as a result of these injuries
would be widespread. Contusion, Coup-Countrecoup, and penetration injuries fall
under the category of local brain damage. The psychological, emotional, and
physiological complications are dependent on the site of the injury because
psychologists know what brain functions occur in specific locations. Locked in
syndrome and second impact syndrome can fall under either class depending upon the
nature of the injury. This is not to say whole brain injuries might not already
contained some localized injuries. For example, it would be reasonable to suggest
that someone with a blast injury at the anterior of the brain might and also have
contusions to the occipital lobe. The cause might be as a result of the brain
smashing against the rear wall of the skull striking the rough surface and
compressing, a cause likely to result in lesions and hematomas.
The consequences of whole brain injuries are much more likely to be hard to
predict because the entire brain has come under some kind of assault.
Complicating the matter, the nature of the assault is likely to make the
consequences more difficult to assess. For example, a high energy blast injury
might produce different results than a low energy DAI. Further complicating the
matter is the angularity and rotation of the injury, making generalized
assumptions in terms of predicting outcomes more difficult, in DAI for example.
Predictions for localized injuries outcomes are more predictable. This part of
the paper discusses what localized brain injury is likely to cause what type of
emotional, cognitive, and physiological results.
The frontal lobe, or cerebral cortex, which an observer can locate right under the
forehead at the far most anterior of the brain is responsible for consciousness,
the initiation of activity, executive control, emotional response, habit memory,
motor activities, and language expression (Lehr, 2009; Carlson 2007). The likely
consequence of this damage to the cerebral cortex would be loss of the ability to
sequence multitasks, paralysis in local areas of the body, fought persistence, and
inability to focus, abrupt mood changes, and changes in personality and behavior.
In addition, the healthcare provider should expect problem solving difficulties.
The healthcare provider might expect to see difficulty in language expression or
Broca's Aphasia, if there is sufficient damage to the frontal lobe to effect
Broca's area (Lehr, 2009; Carlson, 2007). Damage to the parietal lobe presents a
different set of problems.
The parietal lobe, near the top and back of the head is responsible for touch
perception, visual attention, voluntary movements, and the manipulation of objects
(Lehr, 2009; Carlson, 2007). Damage to this area of the brain might result in
object confusion - anomia, noun in verbal amnesia - agraphia, difficulty locating
words in writing - alexia, reading problems - dyscalculia, difficulty with
mathematics - apraxia, lack of physical self awareness and their surrounding space
- as well as difficulty distinguishing right from left, drawing objects, hand-eye
coordination, and lack of ability to focus visual attention (Lehr, 2009; Carlson,
2007). Healthcare providers could expect other visual problems with damage to the
occipital lobe.
The occipital lobe, located at the extreme back of the head or most posterior
region is responsible for vision (Lehr, 2009; Carlson, 2007). Healthcare
providers can expect damage to this area of the brain to result in visual field
cuts, defective vision - color agnosia, and inability to identify colors - and
movement agnosia, and inability to detect movement of an object - as well as word
blindness, hallucinations, and drawing recognition problems (Lehr, 2009; Carlson,
2007). Temporal lobe damage produces its own list of problems.
The temporal lobes, just above the ears, are responsible for or visual
perceptions, memory acquisition, and most importantly problems hearing and
understanding what an individual hears (Lehr, 2009; Carlson, 2007). Damage to the
temporal lobes can result in prosopagnosia, an inability to recognize faces -
Wernicke's aphasia, an inability to understand spoken words - categorization,
difficulty categorizing objects - as well as selective attention disturbances
between what an individual sees and hears - an inability to identify or verbalize
objects - an increase in interference with long term memory and short-term memory
loss problems (Lehr, 2009; Carlson, 2007). Damage to the brain stem is extremely
dangerous.
The brain stem, leading to the spinal cord, lies deep within the brain (Lehr,
2009; Carlson, 2007). The brain stem is responsible for startle response,
swallowing, reflexes, heart rate, hearing and seeing - controls the autonomic
nervous system which includes temperature control, digestion, blood pressure, and
sweating - and the vestibular system - as well as sense of balance. Typical
problems a healthcare provider might observe with brain stem damage would include
dysphagia, breathing and swallowing difficulties, vertigo, nausea and dizziness,
as well as perception/organization difficulties with the environment, and problems
with movement and balance. Likewise, the cerebellum is also responsible for some
aspects of balance (Lehr, 2009; Carlson, 2007).
An observer can locate the cerebellum at the base of the brain (Lehr, 2009;
Carlson, 2007). It is responsible for reflex motor acts, equilibrium, voluntary
movement, and balance. Damage to the cerebellum would result in difficulty with
fine movements, an inability to walk, loss of ability to reach out and touch
objects, tremors, slurred speech, dizziness, and difficulty in making rapid
movements (Lehr, 2009; Carlson, 2007).
Developmental Effects of TBI
The risks and consequences of TBI are developmentally dependant. Most of
this paper addresses the effects of TBI on adults, special consideration exist for
infants, children, adolescents, and older adults. This paper has already
discussed infants – children between the ages of 0 to 4 years old are in one of
the highest risk groups for TBI (BIAA, 2006). Shaken baby syndrome, as the name
implies, only applies to babies. The detection of a TBI is further complicated by
the fact that between the ages of 0 to 4 years old, children are either poor
communicators or do not speak at all. To make matters worst, CT cannot always
detect TBIs (BIAA. N.d.) provided a skull fracture or brain bleeding is not
present as already discussed (RSNA, 2009). Perhaps the best way of detecting TBI
in young children is looking for abnormal developmental changes, developmental
changes that occur rapidly in early childhood (Broderick & Blewitt, 2006). There
are a number of differences between TBI school age children and their peers.
In assessing TBI students an observer is likely to find several deficits,
some cognitive, in attention span, impulsivity, distractibility, poor
organizational skills, frustration tolerance, information overload, social
judgment errors, integration skills, abstract thinking, problem-solving as well as
poor processing information, and reduced performance in relation to ability level
(BIANJ, 2007; The National Dissemination Center of Children with Disabilities,
n.d.). An observer is likely to find the same deficits with learning
disabilities, however – in addition to these deficits an onlooker would also
expect to find additional problems.
These problems might include a wider variation in performance skills, greater
variation in abilities, changes in learning styles before and after injury,
deficits in new learning while retaining old declarative memory, memory deficits
would be more pronounced, social contact would be altered, the inconsistency of
performance would be exaggerated, lack of self control, a broad range of
inappropriate behaviors, and a lack of insight of the problems they are facing.
There would be emotional changes as well.
These changes might include problems regulating mood, and lack of self control.
Again, an observer would be likely to see these behaviors to occur in children
with learning disabilities, however – children with TBI would exhibit additional
behaviors. These behaviors might include overreaction to change – overreaction to
sensory stimulation including light, temperature, movement, and noise – deficits
and awareness of these problems – lack of recognition of cause and effect
relations – inhibition – confusion – and less reaction to rewards and punishments
(BIANJ, 2007; TNCCD, n.d.). It is also important to note that it would be very
easy to confuse a learning disability with localized TBI because of the limited
number of deficits produced by that class of injuries as already discussed. It is
also important to note that a single one of these behaviors would not
automatically constitute a TBI, but clusters would be indicative. TBI in
adolescence pose there own set of problems.
As stated earlier, adolescents between the ages of 15 to 19 are among the
highest at risk groups (BIAA, 2006). It is at about this time, adolescents begin
to enter the workforce (Lash, 2000). TBI adolescents face special challenges with
regard to accurately completing tasks, paying attention, establishing a routine,
remembering directions, appropriate response to feedback, task switching, working
independently, accommodating changes in routines, readiness to redo tasks,
evaluating the quality of their work, using work materials and language
appropriately, and maintaining a separation between work and personal issues
(Lash, 2000). There are many things educators can do to prepare students for this
adjustment.
Lash (2000) recommends a number of academic strategies to prepare
adolescence students for these challenges. These attention strategies include
reducing distractions, dividing work into small sections, presenting information
and asking students to summarize, alert students with cue words using a non-verbal
cueing method. For memory enhancement, again summarize information – maintain
assignment sheets – use self reminders such as calendars, Post-it notes, and
assignment books – educate students on chunking information – teach mental
rehearsal – show students how to incorporate relevant knowledge with prior
learning. To improve the organizational skills, provide students with more time
to review, write checklists, prepare daily routine schedules, review the schedule
with the student, provide written cues to organize an activity, drill sequencing
material, prepare outlines, use color coding materials, and teach self planning.
To develop following direction skills, provide both written and oral instructions,
then repeat the instructions to the teacher, highlighting or underline specific
parts of written or directed assignments, converting complex directions into
simple steps, teaching self checking, and slowing the pace of learning (Lash,
2000). Let us turn our attention to older adults.
While older adults do not fall in a high risk group for TBI, Americans ages
75 and over are at risk for hospitalizations and death as a result of a TBI (U.S.
Department of Health and Human Services Centers for Disease Control and
Prevention, 2008) Symptoms of TBI in older adults include repeated nausea or
vomiting – worsening headaches that do not go away – seizures or convulsions –
difficulty waking from sleep – dilation in both or one pupil – slurred speech –
loss of coordination - numbness or weakness in legs or arms – increased
restlessness – agitation - or confusion. In addition, some medications such as
blood thinners can exacerbate the likelihood of an older adult receiving a TBI,
even if the blow to the head is small (USDHHSCDCP, 2008).
Early Determination, First Aid, and Future Research of TBI
There are several early-warning sign of TBI. These initial symptoms present
themselves as severe facial or head bleeding, ear or nose bleeding, severe
headache, level of consciousness changes that occur more than a few seconds at a
time, discoloration behind or below the eyes, termination of breathing, confusion,
difficulties with balance, leg or arm weakness, unequal pupil size, vomiting,
slurred speed, and seizures (Mayo Clinic, 2008). The Mayo Clinic suggests several
steps for the initial stages of TBI.
The Mayo Clinic (2008) recommends keeping the individual still, but lying
vertically in a dark room with shoulders and head elevated, stop bleeding by
applying firm pressure to the site of the wound with a sterile or clean cloth
unless the help giver believes the skull is fractured, and observe changes in
alertness and breathing. Current research by the National Institute of Health
(2008) suggests that for adults lowering the body’s internal core temperature to
91.4 degrees Fahrenheit (33.0 degrees C) within 8 hours of injury reduces or
reverses much of the effect of a TBI. There are several new research trends the
National Institute of Health is pursuing.
The National Institute of Health (2008) is evaluating the effectiveness of
lowering body temperature of children with TBI as a means of lowering intracranial
pressure and creating an increase in blood flow. Another area of current research
is the use of stem cells to replace or repair damaged nerve tissue. The National
Institute of Health is also pursuing improved rehabilitation programs for those
individuals who already have TBI (NIH, 2008).
Conclusion
The scope of TBI in our society is dramatic. There are 8 types of the
injury including DAI, concussion, contusion, coup-contrecoup, RTBI, penetration
injury, shaken baby syndrome, and blast injury. Brain injuries come in 2
different classes, whole and local brain injuries. DAI, concussion, shaken baby
syndrome, and blast injury would fall in the whole brain damage. On the other
hand, contusion, coup-contrecoup, and penetration injury would fall under the
class of local brain injury. RTBI and locked in syndrome could fall into either
group, depending on the nature of the pre-existing injury and the more recent one.
However, it would fall in the local brain damage in only one of 4 possible
outcomes, when both the previous and most resent damage are both local injuries.
Local brain injures produce are more predictable in terms of consequences.
Localized brain injuries allow us to take advantage of what psychology already
knows about brain structure and what likely consequences would develop as a result
of damage to those sites. TBI is developmentally dependant - it effects infants,
children, adolescents, adults, and older adults differently.
Infant TBI is difficult to detect because of communication problems, TBI children
learn at a slower pace the non-TBI students and in some cases slower with than
children with learning disabilities (BIANJ, 2007). Teachers must employ different
educational strategies for children with TBI. Adolescents with TBI must prepare
to enter the job market - instructors can help here too (BIANJ, 2007). Older
adults are more vulnerable to the most dangerous aspects of a TBI assault, death
and hospitalization because of frailty and medication (USDHHSCDCP, 2008). There
are early warning signs for TBI just after trauma.
There are a number of warning signs in the early stages of TBI, and the
appropriate first-aid can limit and reverse potential damage. Research on TBI is
ongoing, and focuses on new therapies as well as new applications of existing
techniques on different developmental groups. For example, determining if
lowering body temperature in children is as effective as lowering body temperature
in adults as a means of limiting and reversing TBI (NIH, 2008).

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