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HEAD TRAUMA
Head Trauma: Mild Traumatic Brain Injuries
It is a name given to the 10 percent of people who suffer mild closed brain damage and experience a range of symptoms such as mood and anger problems, difficulty concentrating, headaches, and fatigue that last for years or even a lifetime.
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Forgotten head injuries
Organic Brain Syndrome
When the head receives a hard blow, the difference in movement between the brain and the skull creates a force, resulting in traumatic brain injury (TBI).
Although maximum damage occurs at the moment of impact, the frontal and temporal regions are continuously susceptible to bruising and contusions regardless of the point of impact. In addition to the damage at the moment of impact, injury occurs from the brain hitting and bouncing back against the skull, which can cause problems later on. Disruption at the boundary between white and gray matter can lead to axonal fractures.
They may have received mild head injuries from childhood or during sports activities. These injuries can negatively affect electrical activity and impair performance.
The human brain is a 3-kilogram soft tissue sitting within a hard bony arch. This small but vital organ is vulnerable to sudden accelerations and decelerations due to its strong connection with the skull, as well as its geometry and the relative density of different brain regions. Mild traumatic brain injury is associated with damage to the frontal, temporal, and parietal lobes.
Mild head trauma describes cases where symptoms persist 12 months or more after the injury, but MRI and CT scans do not reveal brain abnormalities.
Quantitative EEG (QEEG) in Head Trauma Diagnosis
QEEG is a statistical evaluation of the brain's electrical activity. It is empirical, objective, useful, and suitable for the assessment of head trauma because it is sensitive enough to identify and differentiate various neurophysiological patterns of brain dysfunction associated with head trauma and mild brain damage with a high accuracy rate of 96% (Duffy, J. 2004; Thatcher, R.W. 2000).
Symptoms reported following mild head trauma
Changes in Thinking:
Memory
Decision Making
Planning
Organization-Sequencing
Judgment
Attention
Communication
Reading and Writing Skills
Speed of Thought Processing
Problem-Solving Skills
Organization
Self-Perception
Perception
Safety-Related Awareness
New Learning Processes
Changes in Physical Activity:
Muscle Movements
Muscle Coordination
Sleep
Hearing-Sight-Taste-Smell-Touch (Sensory Functions)
Physical Endurance
Balance
Speech
Seizures-Paralysis
Sexual Behaviors
Personality Changes in Behavior and Skills:
Social Skills
Emotional Control
Frequent Mood Swings
Inappropriate Behavior
Reduced Self-Esteem
Motivation
Anger Control
Denial
Self-Control
Depression
Anxiety
Frustration/Failure
Stress
Irritability/Agitation (Suddenly punching a player on the field)
Excessive Laughter/Crying
Most Frequently Reported:
Attention deficit and difficulty sustaining mental effort
Fatigue and exhaustion
Impulsivity, irritability, mood swings, mood changes
Learning and memory problems
Impaired planning and problem-solving
Stubbornness, lack of concrete thinking and Inability to take initiative
Disconnection between thought and action
Communication problems
Socially inappropriate behavior
Self-centeredness, lack of insight, weak consciousness
Imbalance
Insomnia
Headaches and personality changes
Mood outbursts, mood swings
Consequently, it may be assumed that the person is "quickly angered," impatient, or experiencing a mood disorder or anger problem, or has personality and psychological issues (Duff, J. 2004). The term traumatic disorders is defined in terms of classifying residual symptoms that persist for 12 months or more, and sometimes years after the injury.
Psychiatric Disorders That Can Develop After Head Trauma
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19-48% of children and adolescents have ADHD.[1]
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14-77% have Depression,
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2-14% have Dysthymia,
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2-17% have Bipolar Disorder,
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3-28% have Generalized Anxiety Disorder,
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4-17% have Panic Disorder,
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1-10% have Phobic Disorder,
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2-15% have Obsessive-Compulsive Disorder (OCD),
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3-27% have Post-Traumatic Stress Disorder,
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5-28% have Drug Abuse and Addiction,
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1% have Schizophrenia,
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6% have Psychosis, Paronia,
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49-80% have Personality Changes, and
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24% have Agitation.[2]
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Scientific literature indicates that Past Head Trauma Syndrome can be identified with very high specificity using the QEEG-Data Bank, and that neurotherapy is a highly effective treatment.
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MILD TRAUMATIC BRAIN INJURY (MTBI) DIFFERENTIAL ANALYSIS -
The Brain Injury Probability Index states, with statistical probability, whether a person has a mild traumatic brain injury. It also provides additional evidence supporting the conclusion that the symptoms associated with MTBI syndrome are organically based.
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More than 100,000 studies related to QEEG have been published since 1990. No negative results have been obtained in these studies.
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Since then, the QEEG Neuroguide system has also been approved by the FDA for its useful effect in the diagnosis of MTBI syndrome.
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NxLink Ltd Neurometric Normative Data Analysis System is a published QEEG technology, approved by the FDA. It was approved by the US Food and Drug Administration (FDA) in 1998. All details have been published in various journals (John ER. et al, 1983; John E. R. and Prichep L, 1987; John ER., 1988; Ahn H. et al, 1980), and the neurometric analytical method allows for objective assessment of brain function based on QEEG. NxLink was developed by the New York University Brain Research Laboratories.
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Dr. Robert Thatcher's Neuroguide system, the second FDA-approved QEEG database for differentiating mild head trauma and learning disabilities, received FDA 510(k) approval in 2004. Thatcher's application was followed in 2005 by an application from BRC Operations PTY Limited for its BRC Software product. en.wikipedia.org/wiki/Neurometrics
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Brainscope's Ahead™ M-100 database, developed for the clinical diagnosis of head trauma, has received FDA approval.
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https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN140025.pdf
Drug Treatment for Head Trauma
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Medication can temporarily help with distress, and counseling can help some people understand impulse and anger control. However, there is no evidence in the literature that medication or cognitive therapy effectively improves cognitive problems or concentration in Traumatic Head Injury syndrome.
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There is no proven drug treatment for head trauma.
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Psychiatric medications generally have no effect in the treatment of mild head trauma.[3]
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Publications of 1-9 case studies of antipsychotic medications used in agitation and psychosis following head trauma have shown limited efficacy.[4]-[5]-[6]-[7]
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Only two publications [8],[9] relate to the treatment of individuals diagnosed with Depression after traumatic brain injury. One study was conducted in the United States [8] and the other in Canada [9]. Both studies investigated the efficacy of antidepressants: the first was a randomized controlled trial for sertraline, and the second was an open-label case series investigating the effects of citalopram. It has been shown that neither has a statistically significant effect.
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Considering the scientific explanations above, many psychiatric medications are prescribed to patients despite a lack of scientific support, and patients continue their treatment with medication even if they do not improve.
Neurofeedback Therapy for Head Trauma
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Individuals with attention deficit disorder and mild traumatic brain injury have more slow brainwave activity and coherence abnormalities. Neurotherapy (EEG Biofeedback) uses operant conditioning to provide patients with visual/auditory rewards to encourage them to produce more normal patterns in their brainwave activity.
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Since the 1970s, studies have shown that with neurotherapy, patients can learn to normalize dysfunctional brainwave patterns, helping to improve normal brain function. The latest advance in neurotherapy is the ability to identify specific brainwave patterns that need correction using QEEG.
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Neurotherapy can also be used to improve mental performance and concentration in individuals without Traumatic Head Injury syndrome. There is scientific support for the use of neurofeedback in the treatment of psychiatric disorders resulting from mild head trauma.
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The American Psychiatric Association's publication, the textbook "Neuropsychiatry of Head Trauma," discusses the importance of QEEG neurometric analysis in diagnosis and also recommends neurotherapy (neurofeedback) treatment (Silver et al, 2011).
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The most important textbook in psychiatry, Kaplan & Sadock's Comprehensive Textbook of Psychiatry - 9th Edition, states:
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Quantitative EEG (QEEG) and heart rate variability (HRV) analyses are "scientifically valid assessment methods that provide highly useful clinical information" regarding electromagnetic activity functional dysfunction in the brain and heart in mental health disorders.
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It notes that although there is preparatory evidence for the clinical use of HRV and QEEG in psychiatric assessment, these approaches are not widely used. Neurometric brain mapping is a QEEG approach developed to compare an individual's EEG characteristics with a normative database for the same age group. Neurometric mapping helps in better understanding the functional brain as a result of cognitive impairment and is useful in creating EEG Biofeedback protocols to address specific types of dysfunction.
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Neurometric brain mapping is increasingly used to differentiate cognitive impairments associated with head trauma, medical conditions, progressive dementia, alcohol and drug abuse, depressive mood, and learning disabilities.
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The American Academy of Sleep Medicine recommends EEG Biofeedback for the treatment of chronic insomnia (Sadock et al, 2009).
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Neurofeedback has been shown to be effective in significantly improving and alleviating symptoms of head trauma, and also in improving similar symptoms in cases without head trauma.
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Many studies have shown that neurofeedback treatment is effective in 72-87% of head trauma cases.[10]-[11]-[12]
Questions Commonly Avoided When Taking a Patient History for Mild Head Trauma
The following questions should be systematically asked to each patient:
• Have you ever received a minor or severe blow to the head?
• Have you ever lost consciousness?
• Have you ever hit your head in a way that caused you to be disoriented for several minutes?
• Have you ever been in a car accident?
• Have you ever bumped into something, and if so, did your head move back and forth?
• Have you ever received a blow to the head, hit your head, or had a head-on collision while playing sports (football, boxing, trampoline jumping, sledding, skiing, etc.)?
In our case study, published in the prestigious peer-reviewed journal Electrophysiology of the American Psychiatric Association, showing the effect of neurofeedback therapy on psychiatric disorders developing after head trauma in 40 patients, we found that the patients had been using psychiatric medication for a long time without improvement and had received various psychiatric diagnoses (Depression, Bipolar disorder, Anxiety disorder, Migraine, Panic Attack, Substance abuse, Obsessive-Compulsive Disorder, Attention Deficit Disorder), and that their illnesses were actually secondary, not primary, to the head trauma.
All patients recovered with drug-free neurofeedback therapy, and we found that the recovery was permanent in a 5-year follow-up. 11 patients had been psychotic and paranoid before coming to us, but their psychoses had not been diagnosed. These patients also recovered without medication.
[1] Eme R. (2012). ADHD: an integration with pediatric traumatic brain injury. Expert Rev. Neurother. 12(4), 475–483
[2] Schwarzbold M, Diaz A, Martins ET, Rufino A, Amante LN, Thais ME, Quevedo J, Hohl A, Linhares MN, Walz R. Psychiatric disorders and traumatic brain injury. Neuropsychiatr Dis Treat. 2008 Aug;4(4):797-816.
[3] Anderson V, Yeates K. Introduction. Pediatric traumatic brain injury. New frontiers in clinical and translational research. In: Pediatric Traumatic Brain Injury: New Frontiers in Clinical and Translational Research. Anderson V, Yeates K (Eds). Cambridge University Press, NY, USA, 1–6 (2010).
[4] Burke, J.G., Dursun, S.M., Reveley, M.A. (1999). Refractory symptomatic schizophrenia resulting from frontal lobe lesion: response to clozapine. J Psychiatry Neurosci, 24(5), 456-461.
[5] Michals, M.L., Crismon, M.L., Roberts, S., Childs, A. (1993). Clozapine response and adverse effects in nine brain-injured patients. J Clin Psychopharmacol., 13(3), 198-203.
[6] Schreiber, S., Klag, E., Gross, Y., Segman, R.H., Pick, C.G. (1998). Beneficial effect of risperidone on sleep disturbance and psychosis following traumatic brain injury. Int Clin Psychopharmacol., 13(6):273-275.
[7] Guerreiro, D.F., Navarro, R., Silva, M., Carvalho, M., Gois, C. (2009). Psychosis secondary to traumatic brain injury. Brain Inj., 23(4):358-361. doi: 10.1080/02699050902800918.
[8] Ashman TA, Cantor JB, Gordon WA, et al. A randomized controlled trial of sertraline for the treatment of depression in persons with traumatic brain injury. Arch Phys Med Rehabil 2009 May;90(5):733–740.
[9] Rapoport MJ, Chan F, Lanctot K, et al. An open-label study of citalopram for major depression following traumatic brain injury. J Psychopharmacol 2008 Nov;22(8):860–864.
[10] Sterman, M.B. (1996). Physiological origins and functional correlates of EEG rhythmic activities: Implications for self-regulation. Biofeedback. Self Reg. 21, 3-33
[11] Thatcher, R.W,(1999). QEEG and Traumatic Brain Injury.Defense and Veterans Head Injury Program Issue. Vol.3 N.4
[12] Duff, J.,(2004). The usefulness of Quantitative EEG (QEEG) and Neurotherapy in the Assessment, and Treatment of Post-Concussion Syndrome. Clinical EEG and Neuroscience, 35(4): p. 1-12