Coping With Mild Traumatic Brain Injury

In one second, my whole life changed. One moment I was awake and alert; the next, I was involved in a head-on auto accident.

Days later, my doctor diagnosed me as having suffered a mild head injury, now called Mild Traumatic Brain Injury (MTBI).

At the time, this meant nothing to me, since I looked and felt fine - save for minor cuts and bruises. All I wanted to know was when I could return to work.

In the months that followed, many of the signs of Brain injury, or PostConcussive Syndrome, appeared.

It took me years to understand the consequences of my mild traumatic Brain injury. None of my doctors fully explained my problems, told me what to expect, or explained how to cope.

At first, I felt all alone. However, I soon discovered that there were local support groups for Brain-injury survivors, as well as Brain-injury associations in every state.

Then I discovered the Internet, which opened a worldwide support system.

Through on-line service providers such as Prodigy, CompuServe, America OnLine (AOL), and Microsoft Network (MSN), I have met hundreds of supportive people at all hours of the day.

I discovered that each Brain-injured person and situation is different and unique. Having gone through the experience of MTBI, I know that while the causes of Brain injury may differ, the ongoing consequences are the same.

Survivors, family, and friends need help in the form of knowledge about PostConcussive Syndrome and how to cope with it.

This book is designed to be a practical guide that allows you to focus on the specific things that affect you personally.

Much of the information here may also be useful to people with Aquired Brain Injury (ABI) due to Stroke or Brain Tumors, since any type of injury to the Brain can potentially cause similar consequences.

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In addition to objective information, you will find information that comes from my own experience as well as that of other individuals who have survived MTBI.

Although only their first names (or in my case, my initials) are used, all of the stories you will read are from real people.

In addition, every chapter of this book has been reviewed by field experts, to ensure that the information is accurate. The names of these experts appear in the Acknowledgements.

My recovery from MTBI has been slow. There have been many setbacks. Yet like many others, I am living proof that where there is a will, there is a way to move beyond the effects of Brain injury.

I'm not the person I was before my accident. Instead, I am a composite of the old and the new. However, I have learned that positive changes can take place, if you understand the problems and know how to deal with them.

It is my hope that this book will answer your questions, help sole your problems, and give you hope for a productive life following Mild Traumatic Brain Injury.

Diane Roberts Stoler
Georgetown, MA. USA

Introduction

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Lynn's story is not at all unusual. In fact, each year more than 325,000 Americans suffer mild head trauma from falls, blows, collisions, sports injuries, and violent head movement such as whiplash.

Like Lynn, a significant number suffer debilitating aftereffects for months or years afterwards - despite a perfectly normal outward appreance.

A Look At The Brain

p. 7

In the course of everday life, you have little reason to think about the workings of your Brain. If you suffer a head injury, however, the subject takes on sudden importance.

As with almost any injury, knowledge about the affected organ - the Brain, in this case - will help you and your family to better understand your symptoms and maintain a sense of control over the recovery process.

The human Brain is the most complex organ - an intricate network of some 200 billion Neurons and a trillion support cells (Glia Cells).

The Brain controls all bodily activity, from heart rate and movement to emotion and learning.

It determines a person's abilities, personality, and state of health, and creates a capacity for thinking, feeling, imagining, and planning that exists in no other species.

While the human skull is hard and bony, the Brain within has been likened to custard in a bowl - soft, pliable, and slippery.

Directly beneath the skull are three thin membranes called Meninges that hold pockets of air and about a coffee-cupful of CerebroSpinal Fluid, which cushion the Brain.

Directly beneath the Meninges is the wrinkled, gray-white Cerebrum, which caps the entire Brain. The Cerebrum, sometimes called the Cerebral Cortex, is the largest and most advanced part of the Brain.

It controls problem-solving, planning, and judgement, as well as movement and sensory activity. It consists of veins, arteries, capillaries, and millions of thread-like nerve fibers Axons).

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The thinking process involves a number of different components, including how you register information through attention and concentration; how you store and retrieve incoming messages; and how you reason, plan, organize, initiate, comprehend, learn new information, and create new ideas.

It also involves your ability to understand language, read and write, and do mathematics.

Many people with MTBI encounter a variety of mental effects in the months and years after injury.

We now consider the many different aspects of your thinking ability and provide information abou mental difficulities frequently associated with MTBI.

Along with information about diagnosis and treatment and practical suggestions that can help minimize the effects of such problems.

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Focusing your attention and concentrating are automatic, spontaneous processes of registering information from sensory and other inputs.

In general, problems in this area go unnoticed until some incident causes you to take notice - for instance, a pot boiling over on the stove. And even these situations are usually chalked up to a faulty memory, rather than to problems with attention.

After a MTBI, attention and concentration problems may occur more frequently than before, and your lack of awareness may disrupt your ability to work, maintain social connections, carry out various tasks, or tend to personal matters.

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A problem like Gail's - an inability to select or filter incoming sensations - can cause actual discomfort, as well as difficulty concentrating.

While it can be hard to live with sudden distractibility or over-attentiveness, understanding the nature of your problem and developing a set of management techniques can help tremendously.

Attention is the ability to focus on specific messages; while concentration is the capacity to maintain attention to that message.

These abilities enable you to select which input from bodily sensations and your surrounding environment you wish to respond to, as well as to shift from one activity or thought to another.

It is believed that damage to the upper BrainStem and Frontal Lobes, or diffuse damage to the body's connections to these areas, can cause permanent changes in your ability to attend to and register messages from your body and the outside world.

Like many Brain functions, attention and concentration are dynamic and complex operations. They have three main components: Alertness; Capacity For and Sustained Attention; and Selection. a MTBI can affect any of these.

Alertness is the general readiness that enables you to act upon information from your surroundings, such as sounds, movements, or events.

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For example, it is alertness that creates an awareness that the phone is ringing or that a mosquito has bitten you. Sleep problems, which often result from MTBI, frequently cause problems with alertness and awareness.

Fatigue, medications, depression, anxiety, and the consumption of alcohol can also dramatically dimish your alertness level - sometimes to the point that incoming information is never registered.

Capacity For and Sustained Attention is the amount of information you are able to take in and process at a given moment.

For instance, most people can receive and mentally hold on to a seven-digit telephone number long enough to write it down.

Sustained Attention refers to the ability to focus and concentrate on a task or thought for a period of time, while filtering out other information from your body or from the environment.

After a Brain injury, you may find concentrating extremely difficult due to fatigue, distractibility, or the fact that you cannot stop your mind from wandering. You may encounter problems with reading, following directions, or even holding a conversation.

Also, you may find that you can concentrate on certain things - phone calls, for instance - only at particular times of the day.

Selection is the capacity to choose what you wish to concentrate on. This ability includes all of your senses and occurs spontaneously.

Selection has two main parts - filtering, or selecting an experience to focus on, and shifting, or moving your attention from one experience to another.

Filtering is what allows you to concentrate on reading the newspaper despite a fly buzzing around you and the noise of neighberhood children at play.

If your ability to filter has been affected by your MTBI, you can be impervious to things you should notice or overwhelmed by normal background sounds and distractions.

Overfiltering can affect your general alertness and awarness of danger signals or distractions, while underfiltering can disrupt your ability to focus. In either case, the result is difficult completing any task.

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Shifting is what allows you to quickly transfer your attention from the magazine article you are reading to a friends calling your name from another the room.

Problems with shifting ability can cause you to repeat thoughts over and over, or to linger on a topic or problem long after others have lost interest. This particular symptom of shifting problems is called Perseveration.

Filtering and shifting problems can combine to create Sensory Overload, which most commonly affects the senses of hearing and sight.

Hearing overload can cause sounds to be magnified or make it difficult to understand conversation in a noisy room.

Visual overload creates sensitivity to light, especially the fluorescent lighting used in many offices, stores, and other public places.

Sensory overload can result in mental fatigue, as your mind tries to make sense of all the incoming information.

Factors that can contribute to sensory overload include medications, caffine, hormonal changes, and attention deficit disorders.

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The ability to store and recall information serves as one of the major criteria for determining the severity of Brain injury.

Memory problems are the most common and persistent of all Neurological consequences of MTBI, and symptoms can vary from person to person.

The types of memory problems that can result from MTBI include more than simple forgetfulness. They can involve the inability to recall events or to digest new information and ideas.

The way you remember is also influenced by factors such as attention, organization, motivation, and fatigue, any or all of which may be affected by Brain injury as well.

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The processes involved in memory are very complex. Your memory is actually a number of interrelated networks for storing and retrieving information.

This system allows you to store and recall simple sensory information as well as complex knowledge and personal experiences.

Damage to any part of this intricate system can disrupt your ability to categorize, link, and recall thoughts and experiences.

In turn, if you become unable to recall information, it can become extremely difficult to formulate new ideas or even to act upon old ones.

Memory problems are believed to result from injury to the front or rear portions of the Brain's Frontal Lobes, or to special areas within the Temporal Lobes and to internal structrures such as the Hippocampus and Amygdala.

On occasion, the Parietal Lobes may be involved as well. Memory problems resulting from Brain trauma can vary widely in nature and extent, depending on the site, complexity, and severity of the injury.

Registration, also called encoding, involves the perception of environmental information and sensory input. Sensory impairment can affect how - or whether - certain environmental messages are perceived.

Attention problems also can interfree with the amount of information you are able to register, and the accuracy with which you can do so.

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Storage is the second phase of memory. How you store information is the key to a keen memory. Relating new material to previously learned information, helps form new pathways between Neurons, for more efficient information storage.

There are three types of memory storage: Sensory Memory, Short-Term Memory, and Long-Tern Memory.

Sensory Memory is the storage of information that lasts only seconds but leaves a lingering sight, smell, sound, or sensation - such as when a fly brushes against your skin. This type of memory works hand in hand with attention.

If you cannot recall the name of someone you were just introduced to, or you cannot recall the phone number just recited by the operator, it is usually InAttention that has prevented the information from being stored.

However, if you have deficits affecting sensory memory, you may be unable to play back in your mind what you have just heard. In the case of visual images, you may be unable to picture a bit of information.

Deficits in sensory memory often go unnoticed. After all, if you don't notice something in the first place, you cannot be aware of not remembering it.

Short-Term Memory, also called Buffer Memory or Working Memory, is the part of the memory process that receives and recalls chunks of information for up to one minute.

Short-term memory is what enables you to integrate previously learned information with new information to form creative or novel thoughts; it is critical to daily living.

It is what makes it possible for you to recall where you placed your car keys or checkbook, whether you locked the door or turned off the stove, and whether you have eaten or bathed.

In the best of circumstances, short-trem memory has a limited storage capacity. This type of memory is the most susceptible to interference from pain, stress, fatigue, attention problems, and sensory overload that can follow MTBI.

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For example, if you are interrupted while receiving a bit of information, the thought may be lost.

Long-Term Memory, also called Remote or Secondary Memory, differs from short-term memory in duration, capacity, and manner of storage. Long-term memories are information received and held beyond one minute, becoming learned information.

Research suggests that the capacity of long-term memory is immeasurable, in contrast to short-term memory's limited capacity, and that the reliving or re-experience of memories solidifies their place in long-term storage.

After Brain damage, long-term memories tend to return in fits and starts. Some may never be fully recovered. In some cases, whole areas of information are lost, while related information remains intact.

For instance, you may be able to recall that George Washington was the first president of the USA, but be unable to recall anything about Abraham Lincoln, even with prompting. This type of long-term memory loss is called the *Swiss-cheese effect*.

Usually after Brain damage, long-term memories are the easiest to access, followed by events closer in time to the injury. Verbal memory problems and word-finding deficits can continue for years.

Learning new material - which requires attention, organization, and sensory & short-term memory - is often extremely difficult.

A common sign of long-term memory problems is a vague sense that you are reliving a thought or situation, often called deja vu. This may occur because you are unaware that you are actually recalling a past experience.

Retrieval, your ability to access stored information, is the last phase of memory. Retrieval can occur only if both registration and storage have taken place.

It is based on clues that trigger your memory of how the information was first registered. Smells, sights, sounds, and emotions, for example, are linked to memories; this is why hearing an old song can momentarily take you back to the past.

Research shows that information is more easily accessed if you can reproduce the state in which it was registered, either physically or through hypnosis. Any form of stress, fatigue, anxiety, or depression can interfere with this ability.

Memory-retrieval problems can range from *tip-of-the-tongue* struggles, to an inability to describe a missing word or thought, to Amnesia, or complete inability to access information.

Or other thoughts may intrude, information may be recalled incorrectly, or messages may be lost among other information. Forgetting occurs when a particular memory is not accessible.

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This can mean the information is no longer stored, or there is some sort of internal or external interference with the memory. Often, forgetting results from poor organization of information to be stored.

For instance, if someone tells you his or her phone number, you need to repeat the number or link it with other information. Such as the year you were born or some other familiar number, in order to remember it. Without this step of practice, the information is more likely to be lost.

Other considerations in the proper storage and retrieval of information include emotions and psychological factors; the use of certain drugs, including a number of prescription medications, as well as alcohol and recreational drugs; and auditory or visual distractions.

Many people experience problems with the registration or storage of messages. However, you may not become aware that you have a memory problem, until you try to retrieve information at some later point and find you are unable to do so.

Problems with Amnesia, or total absence of recall, can also occur following MTBI. There are different types of Amnesia:

Retrograde Amnesia affects the ability to recall events prior to a traumatic event. At times, you may recall bits and pieces of certain events, but other memories remain absent. Specific Brain functions such as sensory and motor abilities can also be affected.

Antergrade Amnesia, sometimes called PostTraumatic Amnesia, affects the ability to remember events following MTBI or other traumatic events.

Neither total Amnesia, the complete loss of memory, nor Psychogenic Amnesia, a dissociative disorder, is commonly associated with MTBI.

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Rarely do we stop to consider how it is that we think, for doing so is as automatic as the beating of one's heart. However, after a MTBI, even simple tasks can require a great deal of thought.

This leads people, who are unaware of what has happened to them, to suddenly feel incapable or stupid.

Activities that require Executive Functions - that is, the ability to reason, make sound judgements, and initiate, plan, or organize - may become virtually impossible. This can pose a serious threat to independent living.

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Problems with planning, organizing, initiating, making sound judgements, and understanding are linked to injury of the Brain's Frontal Lobes. Research suggests that executive functions are complex processes involving several Brain areas.

Therefore, it is generalized rather than localized Brain trauma that is responsible for post-MTBI problems with executive functions. Fortunately, the complete loss of executive function is very rare.

The ability to reason and think is not a single process, but an extremely complex network of related processes. Each of your executive functions, depends upon other mental processes, to enable you to receive, comprehend, and act appropriately upon information.

A problem with any one area can affect your overall thinking ability, just as a problem with one small part of the engine can affect the overall operation of your car.

The following are descriptions of some of the higher-level thinking problems that commonly follow MTBI.

Planning is the capacity for thinking ahead and setting goals, whether for the next hour, the next week, or the next year. The ability to plan is the first step in organizing daily living, you must decide what it is you want to do, before you can determine how to accomplish it.

Impaired planning ability undermines your ability to set goals. If you suffer from this problem, you may need to rely on others, to make plans for you or play it safe by avoiding anything other than a repetetive routine.

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Organization is the ability to determine how your daily plans are going to be accompliched. For instance, if you are planning dinner, you must first decide what foods will be included, whether you need to take anything out of the freezer.

Whether a trip to the store is required and when to start preparing each step of the different dishes, included in the meal, so they are all ready at the same time.

Together, planning and organizing require skills in concentration, memory, problem-solving, and sequencing (putting or recalling events in order, or breaking a task into necessary steps).

If you have problems with organization, you may encounter difficulty giving directions or breaking down a task.

If you cannot track and sequence the past, present, and future, it will seem like time has been altered or become nonexistent - as if you have somehow lost time. The emotional result is a general feeling of anxiety, which further impairs your ability to organize, as well as aggravating your symptoms.

Initiation is the ability to carry out the tasks, you set for yourself; the ability to translate thoughts into activity. Even if you ARE able to plan and organize, a MTBI may leave you unable to initiate, the actions you planned.

To family and friends, this may look like a motivational problem; but, an inability to initiate is in fact unrelated, to energy level or ambition.

Rather, the injury may have left your Brain unable to take even the most specific and detailed thought and turn it into activity.

Processing Information is the phase of executive function that is a lightening-quick combination, of a multitude of new pieces of sensory information, with existing knowledge.

A MTBI can affect the speed, duration, and accuracy of the integration, and later interpretation, of such input. Such a processing delay can cost you precious minutes in reaction time, perhaps leading to injury.

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For instance, you may not know to immediately remove your finger from a hot stovetop, if there is a delay or other problem in processing the incoming signal of heat.

Or a clear message may lead to an inappropriate response, such as yelling "Fire!" in a crowded theater and then wondering why you are in the middle of a riot.

Comprehension is the ability to make sense out of processed and registered information - for instance, grasping the meaning of subtle humor or a complex story line in a new movie. After MTBI, you may miss these messages.

You may also be unable to understand verbal directions, commands, or questions, and be unable to make sense of maps and signs.

In extreme cases, this problem can take the form of Visual Agnosia - the inability to recognize familiar objects or surroundings - causing the person to get lost inside his or her own home or become unable to recognize family members.

Decision Making - even mild problems making judgements and decisions can affect all aspects of your thinking. Everyday activities such as cooking or driving, may suddenly become impossible, if you ponder at length what used to be split-second decisions.

You may even find yourself, making business decisions, you later regret. Judgement problems stem from four sources: awareness, selection, memory, and emotions.

Obviously, if you have a problem with awareness, or attention, you may overlook informaion that is needed to make a sound decision, such as the cost of an item you are considering purchasing.

If you cannot focus or remember, you will also have problems making choices that are appropriate. If you are upset or anxious, this too will interfere with your ability to make accurate and appropriate decisions.

Judgement difficulities rang from mild to severe, and they affect concrete behavior, such as exercising caution at a stop sign, as well as higher-level problem-solving.

Many people deny their decision-making problems at first, for fear of appearing incompetent or stupid; but colleagues, family members, or friends often provide insight, by pointing out gross errors in judgement.

Learning - you may retain and use many of your old skills, but be unable to acquire and use new information.

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You may be extremely proficient at using a computer program, you learned prior to your injury; but despite weeks of training, fail to master, even the basics of a new program.

Even though you may not have any muscular or motor problems, you may also encounter difficulty learning new physical activities, such as a dance step or basketball move.

Creativity is the process of developing new and original thoughts, plans, and solutions to problems.

Researchers believe the creative process begins in the Brain's Right Hemisphere. Of course, it is very difficult to form new ideas, if your executive functions are impaired.

You may misjudge the appropriateness or feasibility of an idea, or simply have trouble focusing on or remembering different facets of your thoughts.

In addition, you may have trouble organizing and following through with the creative process, which means that you cannot act on novel ideas that do occur to you.

Trusting others is the first step towards recovery from the reasoning, planning, and understanding problems, that can surface after MTBI. It is important to allow friends and family members to help you, and to let go of the idea, you alone know what is best.

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If you have had a MTBI, you may face much more of a challenge as you go about your work and home life. It helps to take each day as it comes, accepting that your ability to reason, plan, understand, and learn new things may sometimes fluctuate.

The following are some ways to minimize the disruption caused by executive dysfunction:

1. Acknowledge that your Brain has been damaged, and that this will affect your life.

2. Accept the fact that learning new things, making appropriate judgements, and other tasks are now difficult for you.

3. Remind yourself that mental disability is NOT the same thing as lack of intelligence.

4. Tell others of your need for quiet during work periods. If no distraction-free area exists at home, use a study carrel or reading room at your local public library.

5. Discuss with your employer, ways to provide you with a place in which you are able to do your work. This type of accommodation is required, under The Americans With Disabilities Act.

6. Use a VCR or tape recorder to help you improve your ability to sequence sights and sounds. These devices allow you, to repeat bits of information, until you grasp the meaning of what is being presented.

7. When your thoughts become disorganized, seek out a peaceful place. A church, park, or college campus can be an excellent place to regroup.

8. Work at regaining your perception of time, by noting how long everyday tasks take. Put a friend in charge of a timer, then practice guessing how long you have been engaged in different tasks.

9. Observe how children learn best. This can help you develop your own learning strategies.

10. Allow more time than you think you will need, to learn new tasks. Be patient and deal only with today's problem.

Problems with your ability to reason, plan, and understand can significantly affect your frustration level and your ability to work and maintain social relationships.

While recovery from executive function problems can be slow and erratic, it helps to know there is a valid reason for your sudden deficits.

It is also reassuring to know professional assistance is available, to supplement the coping strategies that you develop on your own or learn from others.

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John is still unemployed; but he is working with a Speech/Language Therapist at a rehabilitation hospital, to try regaining his former verbal skills."

Speech Problems, or difficulties using the tongue, lips, and larynx to produce sounds, are a common enough occurrence in everyday life. So are deficits in the ability to use abd understand language.

However, problems of this kind rarely appear suddenly, as they can following a MTBI - a circumstance that can easily overwhelm you, if you must suddenly scramble at home and on the job to compensate for mysteriously absent verbal abilities.

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Several areas of the Brain help to govern your ability to form words, express yourself, and understand spoken language.

Even microscopic Nerve-Cell damage, in one of these areas, can disrupt your ability to process the Auditory stimuli that precede and accompany verbal communications.

Injury to the lower Left Hemisphere of the Frontal Lobe can damage Broca's Area - one of your Speech Centers - and hamper Articulation (the ability to pronounce Speech sounds) and Fluency (the ability to combine sounds and words smoothly).

If other parts of the Frotal Lobe bear the brunt of the blow, both your ability to concentrate on what you are saying and your attentiveness to the conversation of others may be affected. In general, you may be less able to use or understand verbal or written communication.

Damage to Wernicke's Area, located in the upper Left Hemisphere of the Temporal Lobe, can impair your ability to hear and interpret spoken words.

You may have trouble understanding language and thus speak nonsense words out of contex to the conversation.

Language problems can also result if undetectable tearing or stretching of nerve-cell fibers (Axons) hampers your powers of concentration and your ability to store and retrieve information.

In addition, Right Temporal Lobe damage can cause difficulties with NonVerbal communications, which involves gestures, body posture, facial expression, and eye contact.

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Types of communication difficulties can be as different in form and degree as in origin. Whatever your deficit, it is likely to have an impact on every aspect of daily living.

To help you better understand your sudden struggles with speech and language, the most commonly encountered problems are described below.

There are three main types of speech problems that occur after MTBI: Verbal Apraxia, Dysarthia, and DysFluency.

Verbal Apraxia is characterized by the inability to produce purposeful sounds or words on command, even though there are no muscular problems that would interfere with speech.

This can cause you to sound as if you are stuttering, or as if you are having problems with word-finding.

Dysarthia is often characterized by problems with the muscle movements needed to form, or articulate words. It can also affect pronunciation of spoken sounds.

DysFluency, better known as Stuttering, takes the form of hesitant, stammering pronunciation of the beginning sounds of spoken words.

Usually there are a number of *false starts*, as you repeatedly utter the initial sound or syllable of a word, but the rest of the word fails to follow. Or you may involuntarily draw out single sounds for several seconds, as you attempt to summon the rest of the word.

DysFluency after MTBI is most often seen in people who stuttered as children, though it is not known why such an injury can cause stuttering to resurface.

Aphasia is an impairment in the ability to understand or express words or their NonVerbal equivalents. There are many different types of Aphasia, but most fall into one of three categories: Expressive, Receptive, and Mixed.

Expressive Aphasia involves problems with spelling, sentence structure, Verbal reasoning, and/ or the rate of speech. The most common type of Expressive Aphasia is known as Broca's Aphasia.

With this type of Aphasia, a person is able to understand language but unable to produce speech fluently. Instead, words are spoken in a telegraphic manner, using single words and gestures to convey meaning.

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For example, a person with Broca's Aphasia talking about a plane trip might say, "Plane. . . me . . .." and spread his or her arms like wings to make the point. Broca's Aphasia also involves the inability to repeat or write things that are heard.

Another type of Expressive Aphasia is Neologism, a condition marked by grammatical confusion, inappropriate word usage, and the substitution of nonsense words for real words.

Anomia, a third form of Expressive Aphasia, renders a person completely unable to name familiar objects, almost as if he or she were suddenly required to converse in a foreign language.

A lesser form of this problem is Dysnomia, which causes you to grope for words that you know but simply can't think of. "It's on the tip of my tongue", and "You know, the whaddayacallit' are statements characteristic of people with word-retreival problems.

Fluent Aphasia is a type of Expressive Aphasia that results in speech that is properly pronounced, grammatically correct, and effortlessly produced. However, it is often rapid, excessively wordy, and lacking in meaningful content.

Conductive Aphasia is characterized by halting speech with word-finding pauses and concrete rephrasing of words.

Perserverative Speech is remaining overly long on a topic, or the uncontrolled repetition of words, phrases, sentences, or ideas.

Receptive Aphasia is a term that denotes problems with reading, interpreting, and comprehending spoken language. Also called Wernicke's Aphasia, this problem affects the understanding of the meaning of spoken and written words.

Your ability to articulate words may be unaffected, but even though you may be able to recognize the conversation of others, you may be unable to comprehend it, almost as if they were speaking a foreign language.

Or you may be able to comprehend, but find yourself struggling, to process one aspect of what is being said, and missing much of the subsequent conversation. You may also engage in a great deal of meaningless verbalization.

Paraphasia is a type of Receptive Aphasia, characterized by the substitution of parts of words or syllables for words.

Alexia, another form of Receptive Aphasia, is the inability to understand written language.

Mixed Aphasia is a problem with both the comprehension and expression of language.

Sucessful verbal communication requires that several Neurological events occur simultaneously. A malfunction in any facet of the intake or transmission of Nerve Impulses can have a far-reaching effect.

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Because the result can be frightening, frustrating, and a significant handicap to job performance and everyday functioning, it is wise to investigate the cause of any speech or language deficits that follow MTBI.

Your primary health-care provider may recommend an MRI or CT scan, though these tests usually yield negative results in MTBI cases. You may wish to ask about an EEG, which can be significant if it shows a slowing of Brain waves in the Temporal Lobe.

You will probably be given a referral to a Neurologist, and you should ask for a NeuroPsychological Assessment as well. This evaluation should be able to pinpoint the underlying source of speech or language difficulties, and provide a starting point for the formulation of a rehabilitation program.

Articulation and stuttering problems that are aftereffects of MTBI, often disappear on their own within three months. Language deficits may fade more slowly and require additional help. What follows is a look at approaches to resolving communication problems that are slow to correct themselves.

Therapy with a Speech/Language Pathologist helps you learn to work around your deficits, stimulate or retrain your Brain's Speech Centers, and moniter the redevelopment of your verbal skills.

EMG biofeedback can also be very effective for improving speech; it teaches you to identify and recognize individual muscle movements in and around your mouth. Psychotherapy may be suggested, to help you cope with the frustration of feeling misunderstood and being unable to express yourself.

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1. To relax yourself and cut down on stuttering caused by stress, try inhaling deeply through your nose and exhaling through your mouth.

2. Eliminate distractions to conversation. Your speech will flow more smoothly and you will have an easier time with comprehension, if you talk in a quiet place.

3. Try to visualize an elusive word as if it were written on a chalkboard, or try to hear the word in your head. If you still cannot retrieve the word, describe it or substitute another.

4. Ask a friend or family member to give you a prearranged signal, when you are going off on a tangent or failing to make sense in conversation.

5. Be honest about your problem both at work and at home. This will help you avoid embarrassment and promote patience and understanding in people, who might otherwise judge you harshly.

6. Temper any tendencies towards outspokenness for now, and avoid becoming involved in friendly debates. Doing so will save you a great deal of frustration.

7. Watch movies with the sound turned off, to practice interpreting gestures, expressions, body movements, and other forms of non-verbal communications.

8. Explore drawing, music, dance, journal-writing, and the theater, as ways to help redevelop your language skills. Being inventive can help you think of many activities that stretch your ability to express yourself.

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It is difficult to accept sudden deficits in speech or language, and very humbling to have to rely on others to help you communicate. It often helps to look at your verbal deficits as a transient symptom, rather than a permanent disability.

By seeking professional assistance and family support, developing strategies that work for you, and being realistic about occasional setbacks, you will pave the way for certain improvements in your speech and language skills.

Grieving

p. 215

Grieving is a normal process that relieves sorrow and enables us to adjust to the loss. Many people think of grieving as something that happens only after certain specific events, such as the death of a loved one, but it occurs in response to other types of loss as well.

For instance, as you grow older, you periodically mourn the loss of the younger person you once were. This is part of the process of adjusting to advancing age.

If you experience a life-changing event, grieving the loss of the person you used to be is not only natural, but is actually a necessary part of recovery.

p. 216

Grieving The Loss Of Self
The concept of self is complex. It is made up of two parts: the real self and the capacities of the self.

Psychologists define the structure of Real Self as:
1. Self-Image
   • (how you think of yourself)
2. Self-Representation
   • (how you present yourself)
3. SupraOrdiant Self-Organization
   • (how you feel and present yourself over time)
4. The Total Self
   • (who you really are)

These aspects interact with each other. For example, you may think of yourself as a good worker, which may or may not be the case, and you may hope that others think so, too, which they may or may not do.

With the development of the real self come the capacities of the self, which include creativity, intimacy, aliveness, assertiveness, and commitment - all of which enable you to develop thoughts, be caring, feel enjoyment, and pursue your dreams.

The sense of self is not fully developed until adulthood. It is gained through work and through social relationships, especially family relationships and assuming the role of caretaker.

At different points in your life, usually spurred by lifestyle, career, or physical changes, you will relinquish a former self-image and move on.

The natural process can be dramatically altered and/or accelerated by circumstances such as: a loss of employment, natural disaster, a close encounter with death, or a personal disaster. A MTBI is experienced as a personal disaster.

If your injury has robbed you of some of your ability to function at work or at home, this can have a crushing effect; because for most people, one's occupation is a prime source of purpose and gratification in life.

In addition, you may feel less able to interact with your family, socialize, and pursue hobbies. You may have to face the possibility that you will never be as you once were. This experience constitues a loss of self, and loss of self triggers grieving.

p. 217

Experiencing The Grieving Process

Healthy grieving can be more prolonged, perverse, and complicated than you may realize. While not all grieving follows the same pattern, certain phases have been observed often enough to be recognized as typical.

In most cases, the phases of grieving include the following:

1. Denial - This phase includes, being truly unaware of losses or deficits. You may firmly believe that you are no different than before.

2. Anger - This phase often manifests itself, in expression of rage and bouts of aggression, over the injustice of the loss.

3. Bargaining - Here, you try to set terms that will change the eventual outcome. As in, "If I do______ (fill in the blank), things will be different."

4. Disorganization - At this stage, you feel confused and have difficulty ordering your thoughts and behavior.

5. Despair - This phase involves the loss of hope that things will ever be any better.

6. Depression - Here, you experience emotions of hopelessness, inadequacy, and worthlessness. You may have eating and sleeping problems, exhibit anxious or withdrawn behavior, and even think of suicide.

7. Acceptance or Resolution - At this phase, you acknowledge your limitations and feel comfortable knowing that life can continue.

In the immediate aftermath of your injury, you may experience shock, numbness, or bewilderment. Emptiness, remorse, waves of crying, and attempts to regain what you have lost, often follow in the ensuing weeks or months.

Overall, you may feel sad and unable to experience pleasure - alternating, perhaps with tense, restless anxiety.

You may even notice one or more physical symptoms, such as sleep disturbances, loss of appetite, headache, back pain, shortness of breath, heart palpatations, indigestion, dizziness, or nausea.

In an attempt to prevent painful feelings, you may distance yourself emotionally from friends and family. Clearly, grief has many Depression-like symptoms and Depression can sometimes accompany grieving.

A person experiencing normal, healthy grieving only, does not usually have the general feeling of worthlessness typical of a depressed person and he or she may demonstrate episodes of lighter moods intersperesed with depressed feelings - circumstances not seen in clinical Depression.

p. 218

However, the Depression-like symptoms of grieving can last as long as several years, until you can finally consider your loss without feeling overwhelming sadness, and you have begun to invest energy in other thoughts and activities.

Working through and letting go of grief is difficult, but it can be made less so by redirecting your energy to such activities as learning new skills, volunteering your services, or being a support person for another Brain-injured individual.

Gradually, you will begin to acknowledge and accept a new identity, which will allow your grief to fade into memory.

However, if you merely stifle or obstruct your grief, the result may be pathological grief - a paralyzing sadness that lasts longer than a year, with no movement towards recovery from the loss.

In most cases, pathological grief is characterized by continuing denial of reality or preoccupation with death and dying in general. The greater your perceived loss of skills and abilities, the more extensive your sense of loss will be.

Compulsively successful, high-achieving intellectual people, often experience a powerful loss of self if their thinking ability is even very slightly impaired.

Very independent people, who are seen by others as leaders, caretakers, or sources of guidance, may be devastated if they become unable to live up to their previous self-reliant image.

Young adults between the ages of eighteen and twenty-two are tremendously affected by grief after Brain damage.

Psychologists believe this is because at that age, a person has acquired a self-image; but has not yet had the opportunity to establish a sense of achievement or purpose.

In contrast, older people have already enjoyed the accomplishment of some of their life goals and so tend to grieve less.

Children also tend to be less affected by grief, probably because they are unable to recall functioning at another level. They therefore have less trouble blending Brain-damage related deficits into their self-perception image.

Grief over the loss of self is something every Brain-injured person goes through. However, grieving is often not recognized for what it is.

Because the resulting distractibility, anger, fatigue, and other signs, can be masked by or confused with, the symptoms of PostConcussive Syndrome or PostTraumatic Stress Disorder.

Also, lack of insight, which may make you unable to correctly evaluate the impact your symptoms are having on your life, is a typical after-effect of MTBI.

Unfortunately, recognition of grief as a possible cause of post-injury behavior, has eluded many physicans and mental-health professionals, as well as MTBI survivors themselves. Many doctors tend to attribute symptoms of grief following a MTBI, to the physical consequences of the injury.

p. 219

Understanding that there are emotional components to your loss of self is critical, to winning family support, and obtaining appropriate professional guidance. All too often, loved ones say things like "Control yourself", or "Think how lucky you are to be alive".

They may mean well, but statements like these only perpetuate grief. The eventual resolution of your grieving can only come with sympathy, patience, the acknowledgement by you and by others that you are a different person than before - and most important, with time.

p. 220

Within the medical community, there is still much ground to be covered in this area. The idea of grieving following a Brain injury, has been largely overlooked by doctors.

Even the most highly trained Psychotherapists sometimes lack knowledge about Brain injury, much less about grieving the resultant loss of self. Therefore, it pays to keep looking, until you find a professional who understands the sadness and mourning you feel.

- D.R.S.

Grieving is an emotionally painful, but necessary part of life. Fortunately, there are a number of approaches that can assist you as you pass through the stages of the grieving process.

There are now therapists who specialize in grief work, who can enable you to recognize and express your fear and sadness in a *safe* environment, without worrying about how your feelings may affect loved ones or how they might respond.

Assisting rather than resisting grief will allow you to come to terms more quickly with your new situation. Grief therapy, is taiored to several variables, including developmental factors:

The circumstances of your injury, your preinjury personality, and previous experiences you may have had with denial of your grief by support people in your life.

Optimally, the therapist you choose should have previous experience working with patients grieving the loss of self due to injury.

Your doctor, a local rehabilitation facility, or the nearest VA hospital, should be able to refer you to a qualified specialist. As with any mental health professional you choose to work with, it is important that you feel completely comfortable with your therapist.

p. 221

On a practical everyday level, simply recognizing and accepting the grieving process can do a great deal, to make it easier to bear. As you undergo the grieving process, you may find the following suggestions helpful:

1. Acknowledge Your Loss - Ignore any express or implied messages from doctors, family, or friends to *snap out of it* or *get a grip*.

   You cannot get on with your life until you grieve, and resolve your grief; until you recognize that your injury, has made you a new person.

2. Identify & Express Your Grief - Therapy will help you to experience the pain and intense feelings that accompany the loss of self.

3. Commemorate Your Loss - After the death of a loved one, the grieving process is aided by religious or cultural rituals and customs. Some people with MTBI have found it helpful to honor the memory of past accomplishments.

   By collecting mementos of their old selves and burying them - whether literally or figuratively.

4. Acknowledge Your Ambivalence - You may well have conflicting feelings about your injury. Sometimes you may view your survival as a second chance, while at other times you may see it as nothing but a burden.

   Such mixed feelings are normal, but if youdo not recognize them, this inner conflict can pose a considerable barrier to the resolution of your grief.

   Instead of denying conflicting feelings, work towards a balance between positive and negative feelings about your new self and put them into perspective.

5. Learn To Let Go - Ultimately, you must withdraw your emotional investment in the person you once were, in order to go forward with your new life.

   Realize that the person you are today is not a poor substitute, but a composite of your old and newly acquired selves.

6. Move On - Resist viewing yourself as a tragic figure, whom life has dealt a cruel blow.

   Relinguish plans and dreams that revolved around your former self and rethink your goals, based on your present strengths and abilities.

While the recognition of your loss is a painful process, it is important to work toward emphasizing the good qualities you still possess.

With guidance, you can bridge the gap between your pre- and post-injury selves, and emerge with strength, motivation, a redefined creative side, and a restored sense that life has meaning.

It hurts to accept the reality that you may never recover completely, and both recovery and grieving can be slow processes. Once you give yourself permission to grieve, however, you will find the going much easier.

p. 250

- D.R.S.

Denial is the refusal to accept the reality of a problematic condiion or event, and it is the biggest obstacle to coping with any injury.

In the case of Brain injury, where the injury is invisible and the person looks, sounds, and functions (at least in some areas) as he or she previously did, denial is almost a certainty.

Often, denial starts at the scene of the injury, because police or others in authority make a decision about an individual's need for medical care, based opon his or her appearance.

You may assume that the injury, must be minor, since the person either was not taken to the hospital at all, or was released after superficial examination.

If medical help is sought later, the person's complaints are often treated individually - as fatigue, or headache, and they may not be linked to the earlier head trauma.

If symptoms such as uncharacteristic forgetfulness, poor concentration, irritability, or behavior changes occur, you may first suspect an emotional problem or become impatient, when your loved one fails to *snap out of it*. Often the injured person, unable to change, becomes depressed.

p. 251

Realization - If the person's symptoms persist or intensify, you eventually come to realize that something is wrong, and you must give up your denial.

With this unwelcome awareness comes fear, worry, and a sense of vulnerability, for you have somehow lost the person you knew and depended upon, and you do not know what the future may bring.

Financial issues become a concern, as do home issues such as household responsibilities and the care of children.

Helplessness - If you see someone you care about suffering and behaving in a strange and unpredictable manner, you may feel helpless.

Not knowing where to turn or what to do creates an awkwardness that often leads friends and colleagues to stop calling or visiting. Extended family may behave in a similar manner.

The immediate family, who cannot practice this knid of avoidance, may instead become withdrawn and extremely impatient.

Frustration is an outgrowth of the feelings of helplessness that result from your inability to make things return to normal.

It can be extremely difficult to deal with the injured person's inability to acknowledge his or her deficits and reluctance to make needed lifestyle changes.

Often, the injured individual sees his or her primary caregiver as bossy and dominating, and may respond with stubborness or uncooperativeness, or by giving up household responsibilities.

Almost any interaction with the injured person can quickly turn into a control issue, leading to anger and conflict in the home.

p. 252

Anger - Frequently, both the individual with MTBI and his or her family feel anger that the injury has affected their lives.

If the trauma was a result of carelessness or some other fault (real or perceived) on the part of the person with MTBI, feelings of anger are intensified. The anger response strains many marriages, and often causes extended family to withdraw emotional support.

Friendships that have withstood the stresses so far may fall apart at this point, because the friend's anger may not permit him or her to deal with the injured person's unpredictability.

As a family member or friend, you may feel angry that your loved one has changed so dramatically, often permanently so.

Guilt - Anger at the injured loved one leads to feelings of guilt, as you regret your anger and short-temperedness with someone who badly needs your assistance.

You scold yourself for not being more understanding, and feel guilty about not being completely supportive. The fact that you are clearly trying to help does not make you any less ashamed of the annoyance you feel, when the injured person is being difficult.

Sadness - At some point, perhaps after much time spent going from frustration to anger to guilt and back again, you realize that life with your loved one simply may never be the same.

You may get an empty feeling when you look at old photos or when you study the person as he or she is today. Reminiscing about the past and planning for the future become occasions for feelings of sadness and resignation. There is a genuine loss to be dealt with.

Acceptance - Finally, you learn to accept your injured loved one for who he or she is now.

You may not like what has happened to your life, but you accept that your friend or family member, though changed, still has wonderful qualities and many contributions to make to the relationship.

You begin to care for and relate to the new person, rather than bemoaning the loss of the old. Frustration and anger diminish, and loving interaction returns.

p. 253

- D.R.S.

Suggestions

1. Ask your loved one's Neurologist about the medical reasons behind the MTBI person's behavioral and other problems. Simply understanding what is really going on may help reduce your frustration.

2. Educate yourself about the nature of your friend's or family member's deficit.

3. Realize that a person with MTBI passes through several very different phases during recovery. Learn about each stage and try to devise fresh approaches to dealing with them.

4. Ask the Brain-injured person about how he or she feels, and accept these feelings as real.

5. Talk openly about the loss of the old person, and your frustration with the new person's unpredictability.

6. Help the injured person set realistic goals and formulate strategies for achieving them. Track your loved one's progress with a success log, and give him or her full credit for everything accomplished.

7. Get to know the new person, and appreciate him or her not in comparison to the old person, but as a valid and worthwhile individual.

8. Accept your frustration as normal, but express angry feelings to someone other than the injured person. Find other people in similar situations through support groups and on-line computer services.

Living with an individual who undergoes the personal changes associated with traumatic Brain injury is not easy.

It is important to remember that feeling anger or frustration at times is normal, and that despite these feelings, you deserve a great deal of credit for the support and assistance you offer daily.