Brain Injury and Mental Health

Brain Injury and Mental Health   Mental Health and the Brain Working Group March 30th, 2009

Image from the Feingold Gallery

 

Should brain injuries be treated the same as "mental health problems"?

 

Some cases to consider...

 

Doug Bearden

"When he goes dead, his body stiffens and his arms don't move when he walks. In his fifties, Doug Bearden has the all-knees-and-elbows build of a teenager, and cheeks fuller than the past year should allow. In death mode, however, his demeanor strips him of all youthful semblance. His face is stuck in a pale, vacuous blank. Although it makes no sense, Doug thinks he is dead and can't be convinced otherwise, even after a large breakfast and a shower. This is death, he thinks, and there isn't much to do. He paces a few times between the bedroom and kitchen, then decides to take a nap. While he sleeps his wife, Cindy, hopes the feeling of death leaves him, at least for a few hours. Sometimes the death delusion will hover for weeks, other times it may last only a few hours. To her, Doug's death trance is a persistent nuisance, a nagging feeling that doesn't respond to reason or logic. She's tired of it, as tired as Doug must be."

Exerpted from The Resurrection of Doug Bearden in Head Cases: Stories of Brain Injury and its Aftermath by Michael Paul Mason

• Does Doug have a "mental disorder"/"psychiatric illness"?
• How should he be treated?
• Who should be responsible for his care?
• What can/can't be expected of him?

 

Fred C.

During my entire time at the Rehab Home, I was never able to have a genuine conversation with Fred. The first time I met him, he told my co-worker that he knew a doctor in Florida that could "easily fix that problem", which he said as he pointed to her chest. "How's Penn State doing?," my co-worker asked, ignoring Fred's comment. "It's okay I'm just a big fat fucking asshole", he said back, ignoring her comment. I'd soon discover that this is how every attempt at a conversation would start and immeadately end.

Simply saying Hi to Fred would prompt an insult, followed by a verbal self-flagellation, usually "I'm a fucking asshole." Even just walking could result in something like "Excuse me, Ma'am, didn't you wear that shirt yesterday? Did you even go home last night? You're probably a slut." I was told that Fred was in a car accident during a time he was going through a bad break up with a long-time girlfriend, and this was the reason he had a hard time interacting with female staff. It's true that male staff generally had a better rapport with him, but he consistently insulted the people around him and him self as well. Fred lost his entire frontal lobe in his accident, and this is probably a better explanation for his general disinhibition. It was obvious that he had no control over what he said and the moment he said it he immediately felt regret, which is why he always ended up calling himself an "asshole".

Does Fred have a "mental disorder"/"psychiatric illness"?

How should he be treated?

Who should be responsible for his care?

What can/can't be expected of him?

Sam N.

Sam is a former plumber in his late 30's, although his disheveled look makes him look a lot older and most people would guess that he was homeless. He wears a heavy winter jacket in the summer time, his pants zipper is always down (which he is aware of but doesn't care to bother with), and in addition to a limp his arm is constantly flexed and folded close to his body (hypertonia, a result of his injury). He also always carrys a comb in his back pocket, which is ironic because his hair and beard is long and matted. His hair and beard is a sensitive subject for him, probably the only thing he can control in his life, and he refused to cut it when it go so bad that he developed dermatitis.

Sam has a striking preoccupation with food, or at least his favorite foods and drinks. He will perseverate on pears for hours on end. When you walk by, he'll ask "Can I have a big brown pear?". At the end of a conversation, and many times in the middle of it, he'll just say "Big brown pear". Sometimes he can be heard sitting alone watching TV and saying to himself "Big brown pear". He also frequently asks for a pear when he's in the middle of eating one. He also attempts to drink fluids excessively, so much that he once had a grand mal seizure. For these reasons he's on a strict diet and fluid restriction. But when he doesn't get something when he asks (which can be hundreds of times in one day), he can get agitated and occasionally physically aggressive.

He's on what seems to be a bajillion prescription psychotropic drugs, among other types. An antipsychotic for his extreme behaviors, an antidepressant, a mood stabilizer, a sleeping aid, but then also a stimulant. It's hard to know what his behavior and mood is a result of... his injury? his medications? his environment? just "him"? some combination?

• Does Sam have a "mental disorder"/"psychiatric illness"
• How should he be treated?
• Who should be responsible for his care?
• What can/can't be expected of him?

Julie

"Julie offers me a seat on the bench opposite her bed. I look around and take a quick inventory. Her linens are folded and stacked neatly on the shelves in her closet, and her clothes all hang in the same direction. The room is more than tidy; it has that controlled, obsessive-compulsive quality that I've seen in so many homes of brain injury survivors. Julie, Rick once told me, likes things a certain way, and I heard the clinical translation right away. Obsessive-compulsive disorder is such a common trait among survivors that it's often neglected in a physician's diagnosis. In Julie's case, however, her meticulous ways may actually support a sense of comfort, a visual reminder of order in the midst of uncertainty."

Exerpted from A Prisoner of the Present in Head Cases: Stories of Brain Injury and its Aftermath by Michael Paul Mason

• Does Julie have a "mental disorder"/"psychiatric illness"?
• How should she be treated?
• Who should be responsible for her care?
• What can/can't be expected of her?

Roger

Roger is a man in his early 30s, with a wife and 5 year old son, who was a succesful business man before his massive stroke. Recently in the night he has been incontinent of urine. He insists that someone is coming into his room and urinating on his bed. When staff attempt to help him, he demands that they find and punish whoever is doing this to him. Staff try to explain to him that it was he who wet his bed, and that it is not terribly uncommon for someone with his kind of injury to become incontinent. Roger refuses to believe this. Night after night he wets his bed and insists someone is setting him up. Staff try to reason with him and point out how unlikely it is that someone would do that. He soon becomes so agitated that he starts to believe that it is a staff member who is coming into his room at night and urinating on his bed.

• Does Roger have a "mental disorder"/"psychiatric illness"?
• How should he be treated?
• Who should be responsible for his care?
• What can/can't be expected of him?

 

Some questions/issues to consider...

• What makes you "you"? Is there some part of you that cannot be changed by a brain injury or "mental disorder"?

• Is there a limit to "personal agency"?

• Caretaking--who should be involved in a brain injured person's care?

• "Categories" and mental disorders; brain injuries? No two brains are alike, no two brain injuries are alike.

• Policy/lack of resources

 

"Death, redemption, resurrection" is a great metaphor for what it was like to have been in the accident---physically, mentally and emotionally. It took my accident to teach me in a very personal way, that inherent in the word "disability" is the word "ability". -David Feingold

 

Resources on Serendip and the web

Exploring Disability: Images and Thoughts, David Feingold Gallery
My Husband Survived; the Man I Married Didn't (NY Times)
A Missing Son, 'Confused & Unable to Call Home' (NY Times)
War Veterans' Concussions Are Often Overlooked (NY Times)