Excerpted from “Who’s Crazy Now?”
By Todd Clements M.D. & Sue Rueb

Many of us in psychiatry are guilty of failing to thoroughly look for a brain injury before diagnosing someone with a psychiatric condition.  The way we diagnose and treat patients here in the 21st century is still quite archaic.  I compare what happens in psychiatry to someone who goes to the eye doctor complaining that something is wrong with their vision.  The eye doctor goes into a sample closet and pulls out a pair of eyeglasses and has the person wear them for a month and then come back.  If their sight is not better then he goes back into a sample closet and brings out another pair for them to try.  This continues until finally a pair is found that improve the patient’s vision.  The treatment then becomes wearing that pair of glasses.

Thankfully, the eye docs I know don’t do that.  They check you for eye trauma (bleeding, infection, etc…), they check you for stigmatisms, high blood pressure, and other medical problems such as diabetes, which if not corrected will damage your vision.  Yes, they may give you a pair of glasses to wear if needed, but not before they search for the underlying causes of your vision problem.
How can we look at the brain?  X-rays are too low resolution to tell us much in detail about the brain.  They are more or less used to search for skull fractures.  CT scans and MRI’s are higher resolution and used first line in suspected brain trauma.  They are anatomical scans as they evaluate the anatomy, or structure, of your brain.

Functional Brain Imaging

Functional scans look at how your brain is functioning rather than its anatomy.  SPECT (Single Photon Emission Computed Tomography) scans, PET (Positron Emission Tomography) scans and fMRI’s (functional Magnetic Resonance Imaging) are different types of functional scans.  PET scans measure the glucose metabolism in the brain, while SPECT and fMRI measure the blood flow activity.  They basically tell us 3 things: which areas of your brain are working well, which areas are overactive, and which areas are underactive.  Brain injuries will show up in certain patterns.  Usually they present as areas of under activity, but they can show over activity.

SPECT and PET imaging

SPECT and PET scans are known as nuclear medicine studies. They are performed by injecting a small amount of a radioisotope (an unstable atom) into the patient.  The brain cells then take up this isotope and as it breaks down (decays) the energy from it gives off ultraviolet light, which is picked up by the cameras in the scanner.  Functional scans are much more sensitive when it comes to looking for trauma.
It’s not unusual for people with brain trauma to have normal brain structure (anatomy), but their brain functioning be abnormal.  Indeed, one of the hallmarks of brain injury is that neurons may not die, but they undergo chemical changes after an injury and don’t work right.  If brain trauma is suspected and CT’s or MRI’s are normal your doctor should order a functional scan.  Some physicians will even start with a functional scan.

What’s the holdup?

If these scans are more sensitive why aren’t they used more often?  One reason is lack of familiarity.  Many physicians had no experience ordering functional brain images in their residency training and just have never done so.  Many hospitals are not equipped for functional brain imaging—they may have a SPECT or PET scanner, but it is set up for heart, thyroid, or bone studies.  Radiologist on the hospital staff may not have much experience reading these types of brain images, so they have trouble distinguishing what’s normal versus what’s abnormal. 

Insurance companies often won’t reimburse hospitals or patients for functional scans—even though they would greatly help clarify the diagnosis and likely save the insurance companies money in the long run.  Hopefully, as doctors learn more about this technology and advocate for it the insurance companies with change their policies on denying proper medical care for their constituents.  SPECT scans are cheaper than PET scans and they can more readily be done on an outpatient basis.

Other studies

Neuropsychological testing—is not a direct measurement of the brain itself, but rather test cognitive skills, such as attention, learning, and memory—and looks for impairments of skills.  Specific neurological tests have been designed that are known to be linked to a particular brain structure or pathway.  How the person performs on these tests are usually compared to a group of people similar in age, education and even ethnicity.

Neuropsychological testing was used extensively before brain imaging emerged to locate the area of the brain that was injured.  Today it is very useful to evaluate the extent of the effect a brain injury has.

Electroencephalogram (EEG)—measures the electrical activity produced by the brain.  This is recorded from electrodes placed on the scalp.  EEG’s are routinely used to locate areas of the brain that may be causing seizures.  In hospital settings it is also used to verify brain death (no electrical activity).  Areas of injured brain can also show abnormal electrical activity.

The Fallout of Brain Injury

Sadly, many people with brain injuries today are living in the streets of our cities, or jails, or locked up in psychiatric facilities.  Many of these people who were once productive and full of life are now hopeless and just going through the motions of living.  Too many times the end result is wasted resources and wasted lives. 

Drugs & Brains
Alcohol and drug use puts a person at higher risk for a brain injury.  The opposite is also true—brain injury puts a person at higher risk for alcohol and drug abuse.  This is particularly true with a frontal lobe injury where reasoning skills along with impulse control is affected.  These people are often unable to grasp a clear understanding of choices and consequences.  They live in the here and now.  The problem with this type of thinking is when someone offers you drugs your immediate thought is, “Hey, this will make me feel better.”  You’re not concerned with what will happen when it wears off or what kind of trouble you could get into. You’re not even worried that you’re spending your last amount of money to acquire these drugs—you’ll worry about that later.

Alcohol and drugs worsen brain functioning even further.  Not to mention they take someone who has poor reasoning and impulse control and lower those skills even more.  I’ve witnessed on numerous accounts marijuana make someone with a brain injury extremely paranoid.  I’ve also witnessed brain injured people drink themselves into a stupor with alcohol.  They have no idea how to pace themselves or drink socially, basically they drink till they run out or pass out, whichever comes first.

Drugs are probably the single most issue that causes strife between the brain injured and their families.  Many times families will blame that person’s problems on the drug use.  They will see the root of the problem as one of a character deficiency.  It’s easy to make people with impaired reasoning skills buy into this as well.  Family members and friends can see the damage that the drugs are doing and are shocked and dismayed that the user can’t see the effects or is oblivious to them.

Randy, a young man who suffered an undiagnosed brain injury in a rugby game during his junior year of college, experienced a pretty radical personality transformation.  Quiet and shy in the past he became loud and obnoxious.  He rarely drank before his junior year, but started getting sloshed at the rugby parties after the game.  He had received 2 DUI’s, had to go to the hospital once for alcohol poisoning, wrecked his car into the side wall of the dorm, and got put on probation at school for pulling his pants down in the lobby of the ladies dormitory (that’s a whole other story) before his parents had to intervene.  They blamed much of his behavior on hanging around with the rugby team and minimized any effect a brain injury might have had until another doctor pointed out to them that Randy had hung out with the rugby team since his freshman year and had never acted like this.  Several of Randy’s friends on the rugby team reported that he was like a wild man at the parties and would be inebriated to the point where he couldn’t walk usually after only an hour or so.  On numerous occasions they pleaded with him to stop drinking and would take away his keys.  They were frightened by the change in his behavior.

Future Dementia

Brain injury increases the chances of developing Alzheimer’s dementia down the road—this risk can be increased up to five fold.  Alzheimer’s involves the progressive break down of functioning in the temporal, parietal, and frontal lobes.  We now know that genetics are one of the fundamental components in deciding who will develop Alzheimer’s.  Recent estimates suggest that 1 out of 2 people in this country over the age of 85 are struggling with dementia.  The thought is that if you live long enough you will be touched by it.  Prior brain trauma can definitely bring the symptoms of dementia on earlier.

We do have treatments for dementia, but they basically only slow its progression.  This is a huge area of pharmaceutical research with dozens of new cognitive enhancing agents currently undergoing clinical trials.  The hope is that in the next decade a safe medication can be found that will reverse the effects of dementia, right now though our hope is in finding it early.  Treating dementia is similar to cancer—the earlier you find it the better the outcome is.  This is why it is important to recognize brain injuries and monitor these people closely for any signs of encroaching dementia.