Posttraumatic head injury and cognition

Posttraumatic head injuries may leave patients with physical, emotional, and cognitive symptoms that are attributable to secondary brain damage, such as chronic pain, migraines, general fatigue, nausea, fainting spells, loss of equilibrium, disorientation, hypersensitivity, feelings of fear, shame, humiliation, worthlessness or helplessness, depression, anxiety, irritability, memory deficits, inability to follow sequential instructions, comprehension dysfunction, compromised reading and writing ability, and attention disorders.

The plasticity of the human brain is both its power and its weakness. Although the life-sustaining parts of the human brain are “hardwired,” the cognitive parts (located in the neocortex) are not. The part of the brain that allows people to think, to plan, to hope, to dream, to understand language and math, and to recognize themselves and others is highly malleable. It allows them to change their minds and control their behavior, but it is also this part that suffers the greatest loss from brain injury.

Much to the frustration of doctors and patients alike, cellular damage is microscopic and may be diffuse throughout the brain so that conventional scanning technologies such as CT, MRI, electroencephalogram, positron emission tomograph, electronystagmogram, and vestibular testing frequently come up negative.

Addressing secondary cognitive brain damage

As tragic as any traumatic brain injury is, high-functioning adults may suffer the most psychologically. As Dorothy Gronwall and P. Wrightson wrote in Mild Head Injury :

Although high-functioning adults can still score within the normal range on cognitive tests, they do not do so “in a normal fashion. Normal subjects do not need two hours of sleep after the test session to fully recover from the effort, nor do they need to take two to three days to recover fully.”

Unfortunately this ability to achieve an average score is too often interpreted by the medical community as something highly competent people should be able to live with. Left untreated they cannot return to professions that demand high processing speeds, complex analysis, and accurate working memories. As Dr. Jeri Morris wrote in Handbook of Clinical Health Psychology :

Clients typically have little understanding of their metacognition prior to the acquisition of brain impairment. Because much of our cognitive functioning is automatic, they had little reason to consider meta-cognitive processes in everyday life. As a result, after experiencing a brain injury or the onset of a neurologic illness, many have little sense that they have a problem in functioning, even when that problem is quite apparent to others and, in fact, is interfering in their life. Some, for example, may be accustomed to having a good memory and excellent problem solving skills and may assume that they continue to have those abilities. It is impossible to work on a problem that one does not know one has. Others may know they have some cognitive problem but have little idea of specifically what that problem is. It is not likely that one can solve a problem they cannot understand.

By the time posttraumatic head injury patients notice that their memories are not what they used to be or that they have difficulty thinking through a problem they could once have easily solved, massive brain damage has occurred on a microscopic level. Because their symptoms are medically unverifiable and therefore untreatable, they are usually dismissed as the walking wounded, destined to suffer the pain, frustration, and humiliation of not knowing how much longer their condition will last or how much worse it will become.

Using a very-high-field MRI scanner, Dr. Keith Thulborn has observed the brain of a patient who suffered an injury to the Wernicke area (in the left cortex that makes spoken language understandable) initially “rewire” itself first to the right cortex and then back to an adjacent area on the left side even though the Wernicke area remained damaged. This process of rewiring demonstrates the plasticity of the human brain given the right conditions.

The key to the rewiring process is the same that occurs in any form of learning or memorization: attention, intention, and rehearsal.

Regarding attention, Ian Robertson suggests:

Brain sculpture needs your active attention. Indeed, research with animals shows this quite clearly: brain areas that are passively stimulated aren’t sculpted by experience. Brain sculpture generally only happens when attention is paid to that stimulation. What’s more, the attention circuits of the brain are based largely in the frontal lobes and it is these that are crucial for the remolding of the trembling web of connections during the learning of new skills, whether they relate to work, sport or home.

The patient and any therapist must clearly focus their efforts on the areas that require rehabilitation.

Intention is the process that allows transference of learning from one situation to another. Again, according to Dr. Jeri Morris in Handbook of Clinical Health Psychology :

The fact is that most individuals in treatment programs, even those specifically designed to treat cognitive deficits, have no understanding of the actual goals of their own treatment. They may be given a list of deficits (eg, short-term memory problems; visuospatial deficits) for which they have no understanding and to which they cannot connect to everyday functioning. As a consequence, treatment often seems irrelevant. Ask clients in a full-day cognitive treatment program what they did during the day and they typically will reply, “I went to speech therapy,” or “I went to occupational therapy.” Asked further to explain what they did in those treatments, they will say, “I worked in workbooks,” or “I cooked brownies.” To the clients, these activities bear no relation to their lives and are dismissed as unimportant.

Patients must become partners in the treatment and know why they are going through any particular therapy.

The final step is rehearsal, which is a recurring process that activates different neurons within a network to fire and thus strengthen and broaden the network as a whole. The treatment must involve repetition so that the cognitive behavior becomes habitual.

Addressing secondary cognitive brain damage

As tragic as any traumatic brain injury is, high-functioning adults may suffer the most psychologically. As Dorothy Gronwall and P. Wrightson wrote in Mild Head Injury :

Although high-functioning adults can still score within the normal range on cognitive tests, they do not do so “in a normal fashion. Normal subjects do not need two hours of sleep after the test session to fully recover from the effort, nor do they need to take two to three days to recover fully.”

Unfortunately this ability to achieve an average score is too often interpreted by the medical community as something highly competent people should be able to live with. Left untreated they cannot return to professions that demand high processing speeds, complex analysis, and accurate working memories. As Dr. Jeri Morris wrote in Handbook of Clinical Health Psychology :

Clients typically have little understanding of their metacognition prior to the acquisition of brain impairment. Because much of our cognitive functioning is automatic, they had little reason to consider meta-cognitive processes in everyday life. As a result, after experiencing a brain injury or the onset of a neurologic illness, many have little sense that they have a problem in functioning, even when that problem is quite apparent to others and, in fact, is interfering in their life. Some, for example, may be accustomed to having a good memory and excellent problem solving skills and may assume that they continue to have those abilities. It is impossible to work on a problem that one does not know one has. Others may know they have some cognitive problem but have little idea of specifically what that problem is. It is not likely that one can solve a problem they cannot understand.

By the time posttraumatic head injury patients notice that their memories are not what they used to be or that they have difficulty thinking through a problem they could once have easily solved, massive brain damage has occurred on a microscopic level. Because their symptoms are medically unverifiable and therefore untreatable, they are usually dismissed as the walking wounded, destined to suffer the pain, frustration, and humiliation of not knowing how much longer their condition will last or how much worse it will become.

Using a very-high-field MRI scanner, Dr. Keith Thulborn has observed the brain of a patient who suffered an injury to the Wernicke area (in the left cortex that makes spoken language understandable) initially “rewire” itself first to the right cortex and then back to an adjacent area on the left side even though the Wernicke area remained damaged. This process of rewiring demonstrates the plasticity of the human brain given the right conditions.

The key to the rewiring process is the same that occurs in any form of learning or memorization: attention, intention, and rehearsal.

Regarding attention, Ian Robertson suggests:

Brain sculpture needs your active attention. Indeed, research with animals shows this quite clearly: brain areas that are passively stimulated aren’t sculpted by experience. Brain sculpture generally only happens when attention is paid to that stimulation. What’s more, the attention circuits of the brain are based largely in the frontal lobes and it is these that are crucial for the remolding of the trembling web of connections during the learning of new skills, whether they relate to work, sport or home.

The patient and any therapist must clearly focus their efforts on the areas that require rehabilitation.

Intention is the process that allows transference of learning from one situation to another. Again, according to Dr. Jeri Morris in Handbook of Clinical Health Psychology :

The fact is that most individuals in treatment programs, even those specifically designed to treat cognitive deficits, have no understanding of the actual goals of their own treatment. They may be given a list of deficits (eg, short-term memory problems; visuospatial deficits) for which they have no understanding and to which they cannot connect to everyday functioning. As a consequence, treatment often seems irrelevant. Ask clients in a full-day cognitive treatment program what they did during the day and they typically will reply, “I went to speech therapy,” or “I went to occupational therapy.” Asked further to explain what they did in those treatments, they will say, “I worked in workbooks,” or “I cooked brownies.” To the clients, these activities bear no relation to their lives and are dismissed as unimportant.

Patients must become partners in the treatment and know why they are going through any particular therapy.

The final step is rehearsal, which is a recurring process that activates different neurons within a network to fire and thus strengthen and broaden the network as a whole. The treatment must involve repetition so that the cognitive behavior becomes habitual.

Designs for Strong Minds and cognitive rehabilitation

The human mind is a malleable instrument that we can modify to perform with and adapt to the constantly changing circumstances of our lives. Reuven Feuerstein explains that the cognitive behavior of the human organism represents an open system amenable to meaningful structural change. On the physical level, Marian Diamond suggests that the structure and abilities of the cerebral cortex can be changed throughout life by enriching sensory environments.

The DSM program is based on a neurocognitive model that uses attention, intention, and rehearsal to implement learning and behavioral change. What differentiates DSM from other cognitive-based programs is its use of mediation and its large variety of increasingly complex visual puzzles that are organized by logical structures.

Inspired by Reuven Feuerstein, DSM builds on the mediated learning techniques of Feuerstein’s Instrumental Enrichment and Autoplastic Enhancement to help individuals think about thinking and to maximize their potential by eliminating extraneous pressures. DSM uses mediation to direct the patient’s attention to specific information. A mediated learning experience takes place when an individual positions himself or herself between a person and the stimuli impinging on that person and mediates, transforms, reorders, organizes, groups, and frames the stimuli in the direction of some specifically intended goal and purpose. The mediator acts as an external frontal lobe. Mediation enables transference of learning because it makes the learner consciously aware of:

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  The inherent structure of the problem

  
  
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  The intended goal

  
  
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  The relevant information

Because the cognitive exercises do not tap past knowledge, they allow the patient to think, to explore, and to isolate known from unknown, which are prerequisites for cognitive change.

Another attribute that distinguishes DSM from other therapies is that it focuses first on the patient’s functional abilities preinjury. These injuries are likely to have exacerbated any cognitive weaknesses that patients may have had preinjury, so it is important to know how they functioned preinjury to be able to help them learn postinjury. If the patient had trouble dealing with ambiguity preinjury, they are likely to have even more trouble postinjury, and standardized cognitive tests do not address this issue. For example, the spouse of an engineer had complained that after the injury the patient was not reading newspapers or books, which at first seems alarming. On further investigation we discovered that it was something the patient did not enjoy doing preinjury; the problem was not caused by the injury but was exacerbated by it.

Unlike most training programs that emphasize either standardized procedures (eg, answering telephones, filling out forms, baking brownies, and so forth.) or lateral thinking (eg, role-playing, teamwork, thinking outside the box, and so forth) DSM uses mediation and a large variety of visual puzzles organized by logical structures to enhance conscious recognition of various logical structures that have long been associated with intelligent behavior, specifically:

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  Conditional reasoning

  
  
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  Bi-conditional reasoning

  
  
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  Analytic perception

  
  
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  Classification

DSM puzzles and methods tap into the human visual systems. They use graphic puzzles to develop and enhance alternative ways of thinking and doing. To solve the puzzles the learner has to visualize the conditions that make some answers logical and others illogical. In this way the learner experiences both the depth and breadth of neurocognitive restructuring. The organization of materials and the rehearsal present opportunities to create new neural networks the brain needs for permanent change. Throughout the process DSM mediators encourage learners to engage in an internal dialog that transforms the lesson into a meaningful experience.

Understanding when, where, why, and how new learning can be applied creates usable knowledge that enables learners to:

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  Recognize similarities in diverse situations

  
  
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  Assess the ways in which situations are similar and different

  
  
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  Formulate a plan of action in accordance with the assessment

  
  
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  Analyze the degree to which the actions succeed or fail

  
  
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  Gain insight into their own preferences and expectations

Most instruction imparts established theories or routines as a means of leading someone from knowing less to knowing more. With this kind of standard instruction, the learner never has an opportunity to explore the structure or examine the premise on which the lesson was built. Using visual puzzles that require bottom-up thinking to solve, DSM mediators guide learners through the backwaters of their own subconscious thought processes, allowing them to objectively think about how they think and habitually structure information.

Once people have learned to recognize their own organizational behaviors, they can more easily:

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  Verbalize their rationale for doing something in a particular way

  
  
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  Monitor their current level of understanding

  
  
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  Determine when additional information is required

  
  
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  Evaluate new information based on its consistency with what they already know and its relevance for achieving their intended goal

  
  
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  Create analogies that help them and other people advance their understanding of the situation

Through intentional intervention DSM mediators lead learners to an awareness of how their assumptions influence what they see, how they think, and what they do.

The puzzles are not merely optical illusions. To solve them the learner has to visualize the conditions that make some answers logical and others illogical. In this way the learner experiences both the depth and breadth of neurocognitive restructuring.

In addition, multiple experiences requiring the same general strategy (rehearsal) broaden the learner’s perceptual behavior. A wide variety of puzzles allow learners to explore new strategies for organizing information, generating options, making decisions, solving problems, and verifying solutions.

Unlike most learners who are conditioned to looking for correct formulas and single solutions, DSM learners develop “Expert Minds” that:

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  Seek to understand the goal

  
  
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  Organize the available information based on the goal

  
  
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  Structure the problem so that the goal can be achieved

  
  
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  Evaluate the solution’s success at satisfying the goal

  
  
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  Strategize more effective ways of achieving similar goals

Throughout the process DSM mediators encourage learners to engage in an internal dialog that transforms the lesson into a meaningful experience.