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Neuropsychology / psychiatry

Neuropsychology / neuropsychiatry

Introduction

When brain injury strikes, it always brings immediate changes to one degree or another. These changes are complex, and recovery depends on many criteria, such as the severity of the injury and speed of access to treatment and neurological specialists.

The prolongment of effects for each individual will depend on the support structure around them, how the brain injury has impacted daily living and lifestyle choices, changes in independence and much more.

People are forced to deal with a complicated array of unfamiliar and often upsetting issues which they may never have needed to confront previously. An absence of experience or knowledge can create stress, worry and fear about what to do and available help.

Although public awareness of brain injury is slowly increasing, there are still many misconceptions about the consequences and recovery. A lack of knowledge can leave people at a disadvantage because of unknown pitfalls, which can jeopardise the chances of receiving treatment.

At a time when people are vulnerable, they rely on diagnosis, information and follow-up support from medical services. For many people, these things do not happen because they are dismissed or discharged from medical care without seeing a neurological specialist.

A lack of awareness about the possibly dangerous and severe implications of brain injury can mean that people accept incomplete advice without questioning it. All head injuries, including those classified as minor, can have serious consequences. Accessing quality information is essential, and people need to be made aware of what to do if symptoms worsen. For example, a slow brain bleed will need urgent attention and can lead to death.

At times investigation of the degree of trauma to the brain is not carried out. Sometimes there are more critical injuries which take precedence. When and if ordered, ‘routine conventional imaging’ may not always show subtle or microscopic damage, even though it exists. This lack of ‘evidence’ can contribute to people being sent home without information or a follow-up appointment.

Further problems arise when insurance does not cover the treatment needed or minimises what is available. It is common for people to struggle alone, and where there is a lack of diagnosis, families may feel nothing is wrong contributing to misjudgements and sometimes to conflict.

A neurological assessment provides information to everyone involved and will include information about which parts of the brain are damaged and the impact this has on the functionality of the person with the brain injury. The assessment will also assist in an accurate diagnosis and will help people to understand why changes have occurred. 

Brain injury effects

The brain is the most complex organ in the body. It controls and coordinates everything from our heartbeat and breathing to how we perceive and understand the world around us.

A brain injury can cause executive dysfunction and cognitive issues. These typically include problems with attention and concentration, impaired memory and learning, slowed processing speed and reduced problem-solving abilities.

Emotional and behavioural challenges are also common and can include delayed onset of depression and anxiety, as well as problems with frustration and the management of anger impulses, irritability and difficulty with emotional control.

Experience of these challenges can also affect people who have not lost or briefly lost consciousness. The diagnosis in these instances is a concussion or mild traumatic brain injury. On-going post-concussive symptoms can persist for many months or even years.

Many people who suffer a brain injury feel misunderstood. Some people isolate themselves from family and friends and cease social activities because they think others have the wrong impression of them. It can be difficult for them to be assertive about the challenges they are facing and to describe symptoms as many people struggle to understand the changes that have happened to them.

Without outside help and support, issues, including those happening in relationships, can spiral and become more complex. As time passes, it can become even more difficult for people to ask for or seek help.

Medical awareness about brain injury and persisting post-concussive syndrome (PCS) has increased substantially. However, it can still be problematic for people to find a doctor who understands and will assist them in obtaining a referral for specialist neurological help.

If you, or someone you love, has persistent symptoms and on-going functional issues, please speak to your doctor and ask for a referral to a neuropsychologist.

It can help to take information along with you –

Brain Injury A Guide for General Practitioners – Click To Print / Download

Neurological assessment

If a neurological evaluation is needed, there are some things that you can do to prepare. Understanding what will happen can alleviate worries.

First of all, the assessment is not a test or exam, so you don’t need to read-up or study. You will be interviewed about the changes you are experiencing, and it will help if you make a note of areas of concern in the days and weeks before your appointment.

Some people wonder why they need a neurological assessment, especially if they have already had a brain scan. A scan is not nearly as sensitive to cognitive function/dysfunction, and while they may pick up large areas of damage, they don’t give a picture of diffuse injury that occurs at the cellular level.

Fatigue is an issue for many people, and it will help if you get plenty of rest in the days before your assessment. If possible, ask for an appointment at the time of day you are most alert. For some people, this will be the morning and for others, the afternoon. You will be able to take short breaks if needed. Make sure you don’t travel alone as you may be tired at the end of the appraisal, making it more challenging to navigate your way through the processes of any journey. Do not drive if you are tired.

Make sure there is sufficient time to allow for any hiccups on the way and take your reading glasses with you if you need them.

Alcohol, drugs and medications can affect the way we think. Take a note with you of any prescription medications with you and ensure you are entirely free of any recreational stimulants.

The process may take a few hours, and apart from the interview, you will undertake several cognitive tests to evaluate executive skills such as memory, new learning, speed of information processing, spatial awareness, problem-solving and language-related skills and how well you can concentrate. Try not to worry about scores or results but focus on following instructions and doing your best. You may be surprised that you do better than expected because your attention is task-focused by the assessor; you will be following instructions rather than devising your own plan and solutions.

The role of a neuropsychologist

Every brain injury is unique, and no two people are alike.

A neuropsychologist is a brain-behaviour specialist who treats individuals who have suffered a brain injury, whatever the cause. They will help them, and their loved ones, navigate the experience and outcomes of brain injury.

Brain injury brings unpredictable and often traumatic and complex changes which are full of uncertainty and fear.  People must receive sensitive support and guidance through these difficult times to avoid unnecessary complications.

The inclusion of families in rehabilitation is essential and improves the probability of acceptance and integration of treatment. Informed support increases the propensity for better understanding strengthening the resolve of those affected.

Many people only realise the implications of their brain injury long after the event. It can be difficult for them to understand clinical terms and for them to make sense of information when given. Although brain injury is often confusing to the family as well, active participation can help with instilling understanding and coping strategies at home. Involvement also allows families to avoid becoming burnt out, saying things out of frustration and improves the chances of families staying together.

Neuropsychological treatment is comprehensive and focuses on the whole individual addressing cognitive and emotional issues. Unless you know what to look for, many of the outcomes of brain injury are invisible, because you cannot ‘see’ the damage. People can mistake injury-related issues as psychological reactions to change. Many consequences and symptoms manifest insidiously and take people by surprise.

Increased understanding and knowledge in families will improve the way they can reinforce learning in the home environment.

A neurological evaluation determines specific cognitive, emotional, behavioural and physical challenges, as well as any other aspects of the clinical assessment that may complicate treatment efforts.

Neuropsychological tests clarify how an injury has altered the ability of the brain to process information and explains specific changes in behaviour. These exams determine rehabilitation needs and guide treatment. The results of your tests will be discussed with you and someone close to you.

The fundamental goal of cognitive remediation is to set exercises to teach compensatory strategies. These focus on individual strengths to offset impairments and dysfunction caused by an injury.

In many cases, psychotherapy is an integral part of treatment and focuses mainly on adjustment to disability and injury. The process deals with some of the associated psychosocial issues, taking into account the fact that the brain is not working the way it used to.

The role of a neuropsychiatrist

It is important to note that brain injury is not a psychiatric illness. However, some behavioural changes can be an exaggeration of previous personality characteristics. For others, behavioural changes may seem entirely out of character.

In some people, social skills and behavioural management can fragment following brain injury. This fragmentation results in people exhibiting complex and challenging behaviour, often with limited or inappropriate social or sexual interaction which requires the attention of a neuropsychiatrist.

It is essential to be aware that in some instances, extreme behavioural changes may indicate a developing mental illness. Assessment can help people reach the help and treatment they need.

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