What is the difference between a psychological evaluation and a neuropsychological evaluation?

A psychological evaluation is used to evaluate personality characteristics and on occasion will also include some tests of cognitive abilities, such as intelligence or academic abilities.  Psychological evaluations are typically completed when an individual is concerned about emotional abilities, such as depression or anxiety.

Neuropsychological evaluation is a more extensive evaluation of how an individual is functioning with regard to cognitive and behavioral abilities.  A neuropsychological evaluation typically includes evaluation of attention, memory, intelligence, visual-spatial skills, executive functions, language abilities and personality/behavior. A complete neuropsychological evaluation typically takes at least 4 hours to complete, depending on the specific tests administered and the abilities of the individual completing the testing.

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Why do doctors and therapists ask me if I lost my sense of smell when they are evaluating me?

Our sense of smell is also one of the functions controlled by the brain.  An individual who has sustained a brain injury can lose his/her sense of smell due to damage to the part of the brain that controls this ability. You do not have to have an injury to your nose to lose your sense of smell.

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My CT scan of the brain was normal, yet I am still having problems with my memory. How is this possible?

CT scans are helpful diagnostic tests used by physicians to identify physical changes to the brain. CT scans can identify tumors, bleeding, swelling or bruises involving the brain. CT scans are not sensitive enough to identify the microscopic tearing and shearing that commonly occurs after a traumatic brain injury. Therefore it is not unusual for a CT scan to be normal following a brain injury. This simply reflects the CT scan's limitations with regard to identification of the physical changes in the brain. A survivor of TBI may initially demonstrate abnormalities on CT scan, such as swelling or bleeding.  A repeat CT scan several months later, however, may be considered normal.  However, the survivor may still be experiencing functional changes such as memory problems.

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What is the difference between a physiatrist, a psychiatrist, a psychologist and a counselor?

Physiatrists and psychiatrists are professionals who have graduated from medical school and earned either an M.D. or D.O. degree. Physiatrists complete special training in rehabilitation medicine and typically provide services to individuals with brain injuries, spinal cord injuries and chronic pain. 

A psychiatrist completes additional training in mental health treatment. Physiatrists and psychiatrists can prescribe medication.  A psychologist is an individual who has graduated from a doctoral program and earned a Ph.D. or Psy.D.

Psychologists receive training in the diagnosis and treatment of mental health issues.  Psychologists administer psychological tests and provide therapy services to address mental health concerns. 

What is the difference between a traumatic brain injury (TBI) and an acquired brain injury (ABI)?

A traumatic brain injury is the result of an injury to the brain by an external physical force that may produce a change in consciousness and results in impairment of cognitive abilities, physical functioning or changes in personality/behavior.  Types of TBI include diffuse axonal injury, concussion, contusion and coup-contrecoup injury. This kind of injury can occur from car accidents, falls, playing sports or physical violence. 

An acquired brain injury is an injury to the brain that occurs after birth and is due to a change in neuronal activity, usually as the result of another medical condition. Examples of ABI include anoxia, which is an injury that occurs when the brain does not receive any oxygen, or hypoxia, when the brain receives some, but not enough oxygen.  Causes of ABI can include heart attacks, aneurysms, near drowning, choking, electrical shock or airway obstruction.

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What is "Second Impact Syndrome?"

Second impact syndrome is also known as recurrent traumatic brain injury and can occur when an individual has a second brain injury before the first injury has healed.  The second injury can occur days or weeks after the first one and is more likely to cause swelling of the brain and widespread damage.  Individuals experiencing second impact syndrome need to seek emergency medical treatment immediately as death can occur rapidly following the second injury. This is why it is important that anyone recovering from a brain injury take all possible precautions to avoid further injuries until all of their symptoms from the first injury have resolved. This includes all types of brain injuries, even concussions.

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I have been discharged from therapies but want to continue to work on improving my memory and other cognitive skills.  What are some things I can do to continue to work on my cognitive abilities?

Just as physical exercise is good for the body, mental activity is good for the mind.  Continuing with any strategies or home exercise activities that your therapists have recommended is important.  In addition, continuing to challenge yourself with mental activities every day will help you maintain the abilities you gained in therapy and help you continue to improve.  Reading the newspaper, magazine or a book can help with concentration, reading and memory. Watching the news keeps you up to date on what is happening in the world. There are many games that you can purchase that are not only good family entertainment but also require reasoning skills.  Doing crossword puzzles or word searches can help if you have difficulty with language skills.  The most important thing is that you find activities that you enjoy doing, as you will be more likely to continue them. Consistently applying the strategies you learned in therapy to your daily life will allow you to adapt more quickly and accomplish your goals.

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When I wake up in the morning I feel good and am usually able to get a lot of things done.  By afternoon, however, I'm pretty tired. I've been told this may be due to cognitive fatigue. What is cognitive fatigue and what can I do about it?

Everyone has a limited amount of energy available each day to accomplish our goals. The amount of energy we have varies due to a variety of factors, including how well we sleep at night.    How quickly we "spend" our energy during the course of the day has an effect on our level of fatigue. After a brain injury, individuals typically find that certain activities require more energy than they did before the injury.  For example, eating at a busy restaurant can use up more energy for an individual who has difficulty with attention and is easily distracted.  Cognitive fatigue occurs when you are reaching your limit with regard to the amount of energy you have left to spend. One strategy to combat cognitive fatigue is pacing. Pacing involves first identifying how long an individual can work at various tasks before becoming fatigued. 

For example, you may find that you can work for an hour on a task, such as paying bills, in a quiet environment but can handle attending to conversations in a crowd for only thirty minutes. Identifying your limits and then scheduling breaks throughout the course of the day can help you combat cognitive fatigue. Planning your day in advance when possible can also help.  For example, if you know you have a family reunion to attend on Saturday afternoon at the park, you may want to plan quiet activities at home in the morning, instead of going to the grocery store.

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My doctor has recommended a functional MRI.  How is this different from a CT scan or MRI?

A functional MRI or fMRI is an image of brain activation as a function of change in cerebral blood flow or blood oxygenation.  Usually the analysis is based on blood oxygenation changes. When a part of the brain is activated there is an increase in oxygen rich blood.  Changes in neural activity are evaluated by measuring changes in local blood oxygen levels in the brain during performance of a specific task. During the completion of fMRI the individual is required to complete some cognitive activities, such as memory tasks.  The scan then reveals the changes in blood oxygen levels in the brain during the completion of the task. This allows your doctors to determine how your brain is processing specific types of information. Individuals who have had normal CT or MRI scans have show abnormalities on fMRI.

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What is the relationship between brain injury and depression?

Depression is the most common psychiatric diagnosis after brain injury. Individuals may experience symptoms immediately after their injury or not until several years post injury. Individuals with depression after brain injury have poorer rehabilitation outcomes, poorer quality of life, less social and recreational activity, greater caregiver burden and poorer subjective well-being. As a result it is important that individuals receive treatment for their depression. The preferred form of treatment for individuals with depression following brain injury is psychotherapy. Medications can also be beneficial but caution should be taken as individuals with brain injury are more likely to experience side effects from these medications.

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Why does my treatment team tell me not to drink alcohol now that I have had a brain injury?

It is important to realize that alcohol is a neurotoxin – in other words, it kills brain cells.  After a brain injury alcohol can interfere with the healing process. Alcohol can also cause seizures. While this is pretty rare for healthy individuals, after a traumatic brain injury your risk for seizures is increased due to the injury. Drinking alcohol increases that risk even further.  Individuals who drink to the point of intoxication also demonstrate changes with regard to their cognitive skills, with judgment being one of the first skills impacted. As a result, intoxicated individuals may do things that put them in situations where they may be harmed and perhaps sustain another brain injury. Some individuals may turn to alcohol as a means of coping with their loneliness, depression or anger.  Research that has been conducted to look at safe alcohol consumption for individuals with traumatic brain injury has concluded that there is no safe amount.

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The physician and therapists told me my son is at a Ranchos Level V. What does this mean?

The Ranchos Los Amigos Scale is a tool used by rehabilitation professionals to measure recovery from brain injury. The scale ranges from I to VIII. Briefly, an individual at a Ranchos I is someone who is in a coma. Ranchos II and III are reflective of some beginning responses. Individuals who are agitated and confused are exhibiting characteristics of Ranchos IV. As agitation decreases and the individual remains cognitively confused he is demonstrating a Rancho Level V. Ranchos VI is characterized by an ability to respond appropriately to automatic types of behaviors. At this time individuals are usually being discharged from the hospital and initiating outpatient therapies. Ranchos VII and VIII measure continued gains in cognition. It is important to realize that an individual at a Ranchos VIII will still demonstrate cognitive limitations involving higher level abilities.

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Can physical therapy help with balance problems after a brain injury or should you just “learn to live with it”?

Although balance disorders are challenging, there are exercise protocols specifically designed to address our balance/vestibular systems. This system integrates information from different parts of the body to give us good balance and tolerance to motion. The programs are highly effective, but good outcomes are strongly correlated with thorough evaluation and a multidisciplinary approach. Contact your physician to see if physical therapy may be appropriate to treat your balance dysfunction.

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Chronic low back pain following an injury can limit one’s participation in exercise as part of a healthy lifestyle. Is it okay to forget exercise because it can hurt and become a “couch potato”?

Unfortunately, chronic pain (low back or elsewhere), can induce a cycle of pain, decreased activity, increased dysfunction and heightened pain. This pain-disuse-dysfunction cycle must be broken. By selecting an appropriate exercise modality, you can build a strong, healthy musculoskeletal system to manage pain and reduce the associated dysfunction, without provoking the pre-existing low back pain. A physical therapist can help identify appropriate ways to accomplish this, along with cardiovascular conditioning to optimize function and reduce the debilitating effects associated with this cycle.

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What is aphasia?

Aphasia is a language disorder that results from damage to the language centers of the brain. It can affect a person’s ability to understand language as well as the ability to express thoughts. Aphasia commonly occurs following a stroke but can occur following traumatic brain injury, brain tumors or an anoxic episode (lack of oxygen to the brain).

Depending on the area of the brain affected, people may experience expressive or receptive aphasia, or a combination of both. Expressive aphasia is commonly characterized by difficulty with coming up with the right word (“it’s on the tip of my tongue”), difficulty writing, and using gestures to communicate thoughts. Receptive aphasia, on the other hand affects one’s ability to understand what is being said or read. Even though a person may be able to hear or read words, they may sound or look jumbled.

Several factors may contribute to the severity of difficulties with language. They include severity of damage to the brain, age, educational level and health prior to injury. One person might only be able to speak in single words, whereas another may have occasional trouble finding the right word in a conversation. Another person may be able answer simple questions and directions (i.e. “did you like the movie?” “point to the comb.”) while another may have trouble following multiple directions or have difficulty reading more than a simple one or two paragraph article.

A speech-language pathologist assesses and treats people with aphasia with drills and strategies to improve communication. Exercises vary based on the severity of the problem and take into account a person’s language needs.

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My speech is fine, but after my brain injury my doctor referred me to a speech-language pathologist. Why?

The term speech-language pathologist is deceiving. Speech-language pathologists (SLP) are skilled in assessment of speech, language, and cognitive functioning. Following a head injury or other trauma to the brain there are cognitive (thinking skills) problems. Sometimes these problems will be quite obvious whereas other times they may be quite subtle. In addition to speech and language, an SLP will observe and assess swallowing, memory, orientation, problem solving reasoning and attention. Mathematical skills, planning and organizational skills are also areas in which speech-language pathologists evaluate and treat.

The speech-language pathologist is part of the rehabilitation treatment team. Once the evaluation period is completed, results of testing and recommendations for treatment are shared with the client, family members, and the clinical treatment team.

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What are common memory problems following TBI?

Short term memory loss is a common impairment following TBI. Generally long term memory, such as recall of historical information, childhood and other events prior to injury are preserved. The degree and location of injury affects the severity of memory problems. Some examples of short term memory loss include:

• forgetting what happened during the day

• forgetting placement of items

• forgetting tasks completed throughout the day

• losing “train of thought” during a conversation

• trouble with note taking

• difficulty retaining information in class

• difficulty recalling the main details of a recently read article or book chapter

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How can I help my family member remember appointments and day-to-day events?

Daily routines are helpful. Encourage your family member to keep a calendar and write down appointments. If he can not do this himself, set aside a time during the day to review and write down information.

Keep a notepad and pen near the phone to write any phone messages.

Create a “To Do” list for the day. Have your family member check off each task or activity as it is completed.

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I have difficulty focusing on what I’m doing. How come?

Attention is a vital part of our everyday functioning. All of us from time to time become distracted, whether it is a phone call in the middle of cooking dinner, or being interrupted to attend a meeting while in the middle of writing a report.

When a person sustains a brain injury, attention is an area of cognition that impacts the ability to concentrate and focus for various amounts of time and in various conditions. The following types of attention may be affected:

Focuse: the ability to attend to an activity or task with no other distractions. For example a person might do a crossword puzzle in quiet.

Selective: being able to attend to a task and block out unimportant information. For example reading a book while playing background music.

Alternating: The ability to switch between tasks. This is especially noted in real-life situations. For example: working in an office and being interrupted by phone calls, filing and greeting clients.

Divided: The ability to do two or more tasks at the same time. One of the most common examples is driving a car while changing radio stations and looking for an unfamiliar exit.

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What is Dysarthria?

Dysarthria is a speech disorder that results from involvement of the nervous system. These conditions include stroke, progressive diseases such as Parkinson’s, and less frequently following traumatic head injury. It affects the quality of speech production and is often characterized by slurred speech and facial weakness. Symptoms include limited tongue, lip and jaw movements, breathy voice quality, drooling of saliva, chewing and swallowing difficulty, change in voice quality, slow or rapid rate of speech and abnormal intonation (rhythm).

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After my injury, it was recommended I use a cane for walking. I’d rather not use an “assistive device” to get around. Should I get rid of it?

Without question, we are driven by an inherent desire to be physically independent. None of us want to feel we need a device to walk or may be uncomfortable with the attention it may create. However, walking safety is the primary issue. If a device allows you to be independently safe and mobile, then it is well worth it. We must minimize our risk of a potential fall and the injuries that may be associated. Walking quality is another consideration; is your walking more energy efficient and even/symmetric using a cane? Striving for the most normal quality gait is important for good biomechanical joint and muscle function, keeping additional stresses off our body to avoid pain and dysfunction. Carefully consider these areas and discuss your feelings with your physician to determine if gait training/gait analysis may be of benefit before your decide to leave the cane behind.

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I often feel very tired and dragging, like I’m “out of gas”. It makes it hard for me to start a project or accomplish anything. What’s my problem?

After brain injury, physical de-conditioning is prevalent. Your lifestyle may have become more sedentary, medications may cause lethargy, and recovery from injuries may have delayed your return to your daily routine. All of these factors may contribute to reduced physical stamina/endurance. In addition, changes in internal drive and motivation, plus initiation of activity, can be problematic following brain trauma due to cognitive impairments. Good, old fashioned physical activity is the best way for improving our physical endurance to combat the feelings of lethargy and de-conditioning. A prescribed conditioning program can improve our energy levels and our energy reserves to support a more active and productive lifestyle. Cognitive aspects can be addressed by appropriate team members to support success in your program. A physical therapist can help identify conditioning activates that suit your interests and goals.

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My brother had a brain injury and was in the hospital for three months. He is home now and going to outpatient therapy. It still takes him a long time to get dressed in the morning so I help him instead of letting him do it himself. I figure that he is practicing how to dress himself in therapy, so it is not important that he dress himself at home. My sister disagrees. Who is right?

While it is important that your brother participate in outpatient therapy, it is also important that he practice these skills as often as possible. The purpose of practice is to help the brain re-establish the connections that are needed to complete tasks such as dressing. The more opportunity your brother has to practice, the more progress he will make in his recovery. It can be frustrating to watch a loved one struggle to do tasks that used to be so simple. Sometimes it’s hard for family members to allow the person to do things, as the family member feels it is their responsibility to do it for them. Try to allow extra time for your brother to complete tasks so that you don’t feel rushed and frustrated. Remember, encouraging your brother to do things for himself now whenever possible will help him be more independent in the future.

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Since her discharge home from the hospital my daughter has been telling us that she wished she hadn’t survived the accident. This really upset’s us, as it is a miracle that she is alive today. How should we respond when she says this to us?

Your daughter may be expressing feelings of grief over the significant changes in her life as a result of her injury. This is a normal part of the grief process and you should encourage your daughter to talk with you and a counselor about her feelings of loss. While most individuals who recover from a brain injury experience similar feelings, it is also important to make sure that your daughter is not clinically depressed and suicidal. While it is common for individuals to express feelings that they wished that they had not survived their injury, this does not mean that they currently wish to die. An individual who is expressing a desire to end their life needs immediate medical attention to ensure their safety. If your daughter is expressing suicidal thoughts, you should call her psychologist or doctor immediately and alert them to the situation.

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Please tell me about Post traumatic amnesia – how long does PTA last?

Post traumatic amnesia refers to a disruption in the memory system of the brain as a result of an injury. PTA begins at the time of the injury and includes the coma period. It does not end until the individual is able to continuously report events that have occurred. In other words, a person may be out of coma and talking with their family members but has no recall of the conversations. This individual is still experiencing PTA. As a general rule of thumb PTA usually lasts 4 times the length of coma. So an individual who is in a coma for two weeks typically experiences PTA of eight weeks. As an individual recovers from the injury he/she will begin to remember events of the day and days before. However, he/she will have no memory of the events immediately following the injury. This is not due to psychological trauma, but the neurological injury itself. The inability to remember hours, days or weeks of your life can be stressful and uncomfortable. Reassuring the individual and letting him/her know what happened during this period may be helpful. Most important, however, is acknowledging that their PTA has resolved and that they can remember events now.

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My daughter underwent a lobectomy for epilepsy. Most of her right frontal and temporal lobes were removed. Since the surgery, she has had some major behavioral issues. I've tried everywhere that I can think of or that has been recommended to me to get her help to no avail. Any suggestions you can give would be most appreciated. Thanks.

I’m not sure how old your daughter is or what treatments you have tried thus far, but hopefully some general guidelines will be helpful. First of all, remember that our frontal lobes play the role of mediating our behaviors. Individuals with lesions involving the right frontal lobe tend to display more behaviors related to impulsivity and anger. Behavior problems associated with the frontal lobes are usually divided into five different areas: problems of getting started, difficulties in making mental or behavioral shifts, problems in stopping, deficient self awareness and a concrete attitude, or loss of the ability to think abstractly. Right temporal lobe lesions typically result in difficulty with nonverbal sound discrimination, recognition and comprehension. Individuals with temporal lobe lesions may also have difficulty with fine visual discriminations, organization of complex data and odor perception. When dealing with behavioral issues it is also important to consider both the individual’s abilities and their environment, as both play an important role.

The first step in addressing a behavior issue is to determine the exact cause of the behavior. For example, is your daughter experiencing difficulty with changing tasks and becomes frustrated when this is required? If so, treatment needs to focus on strategies to address ways to assist your daughter in transitions. You may also want to modify the environment to limit situations that are likely to increase the behaviors. Make sure that you understand your daughter’s limitations and strengths so that you do not place her in situations where she does not have the ability to succeed. For example, we would not expect someone to perform well in a job when that person does not have the knowledge or skills needed to succeed. This same philosophy applies to your daughter. If she is easily overwhelmed by noise and sound, taking her to a concert would likely result in an increase in behaviors. Keeping a log of behaviors will be helpful for her treatment team. You may want to contact your local chapter of the Epilepsy Association and area hospitals that have epilepsy programs to determine if they offer any specific treatment programs for your daughter.

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My daughter is not able to communicate with us since she had a severe brain injury. Her doctor told us she has receptive and expressive aphasia. Her arms and hands seem to work fine. Why doesn’t someone recommend that she learn sign language?

Aphasia occurs as a result of an injury to the language center of the brain. The degree and type of impairment varies based on the injury. For example, some individuals may be able to understand what others are saying, but are not able to verbally respond. When an individual is diagnosed with a language disorder treatment from a speech therapist is indicated, with a focus on regaining speech functions and developing compensatory strategies to help the person develop communication skills, such as through use of gestures or pointing out pictures on a daily communicator. Learning sign language is a complex task. While the hands are used as the primary means of communicating, the individual still needs to be able to access language functions in the brain. Due to injury in the language center, this may not be possible.

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What is neural plasticity?

Neural plasticity is the medical term used to refer to the ability of nerve cells to fight chemical and structural changes that can eventually kill them if not controlled. It can also refer to the ability of nerve cells to change their activity in response to changes in the environment, store information from the environment and to allow the individual to move about and survive. There are three basic types of plasticity in the brain. Developmental plasticity refers to the immature brain being shaped by early life experiences, as seen in a baby as he/she grows and develops. Activity dependent plasticity is something that occurs after years of practice of a skill and learning and memory. It refers to the formation of new connections in the brain as a result of experience and learning. Examples include learning to play a musical instrument or drive a car. Injury induced plasticity refers to the altering of the balance of activity in the brain due to injury.

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