The first is when direct forces are applied to the head. This mechanism of injury usually results in a loss of consciousness, in some cases, very briefly. DAI results in the shearing of neural pathways in the connective white matter, which forms the subcortical regions of the brain. It results in a metabolic cascade that evolves over minutes, hours and days. The effect on function is cumulative over time rather than immediate.
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This trajectory is likely to have given rise to the misinterpretation that evolving cognitive symptomatology is psychological rather than organic. Of course, over time, as individuals get the feedback that their brain and body is not functioning as it once did, their mood will be affected, which results in reactionary psychological issues. I have assessed a wide variety of patients following what has been classified as mTBI. What is striking is the undeniable similarity and consistent patterns of what people report, which does not seem to be influenced by gender, age, social strata, ethnicity or which referral path they have come through.
What are some of the limitations of brain-imaging techniques in this context? A CT scan, such as is routinely used in emergency departments when individuals present with a head injury, would be normal for mTBI. A standard MRI produces a more detailed picture of the brain, but, like a CT scan, they are insensitive to subtle vascular or diffuse axonal injury. There are more sophisticated MRI techniques that show vascular and white matter damage such as gradient-echo and susceptibility weighted imaging. These scanning techniques can show micro-bleeds, which is an indication of white matter injury including DAI but unfortunately are not routinely available, especially for those that have no overt signs of a brain injury.
Diffusion-tensor imaging DTI is another tool that is often used in research but not clinically, despite its being a sensitive marker for white matter injury. In sum, standard neuroimaging lacks the sensitivity to identify damage at a microscopic level, which is the level at which DAI occurs. Individuals are reassured, albeit falsely, that the scans and therefore their brains are normal.
This is at odds with their experience and clinical outcome. What kinds of neuropsychological assessments can reveal mTBI? For me as a diagnostician, it is about identifying tests that highlight the brain regions that are most susceptible to being affected. I am reluctant to name specific neuropsychological tests in an effort to keep them as much as possible out of the public domain.
Whilst I assess all cognitive domains, I interrogate frontal and subcortical functions more heavily. In terms of memory assessment, I look at the pattern of performance to help differentiate whether there is a deficit in encoding, retention or retrieval and whether there is any benefit gained from cueing.
Furthermore, I assess post-traumatic amnesia, albeit retrospectively. This line of questioning helps to elucidate what information the individual recalls minutes, hours and days after the injury. This information is important in the classification of brain injury severity. There are limitations in solely basing neuropsychological formulation on neuropsychological tests alone. Our understanding of executive functioning, in particular is evolving — seek out recent research by Donald Stuss and by Rodger Wood and Andrew Worthington.
It is being more widely recognised that observed neurobehavioural changes indicate executive dysfunction even when performance on standardised neuropsychological tests is not significantly different from the individual pre-morbid level. Bass Guitar Nick Ghanbarian. Mastering UE Nastasi. Release Date February 6, The Walking Wounded Bayside.
The Walking Wounded. Carry On.
I and I. By assuming that closure is necessary, but unattainable, they have difficulty finding language and rituals to grieve.
The Walking Wounded may go down three general paths: 1 They may never find what they consider closure but continue to seek it. Importantly, most individuals will neither fit neatly, nor remain permanently, in any of these categories. I use these labels to help us understand why people argue they cannot find closure. Creating new rituals for grieving is not necessarily a bad thing.
We should be open to people creating their own roadmap. In our contemporary society, we increasingly see people and institutions develop and sell policies, products, and services in the name of closure. There are no guidelines or licenses needed to promise this elusive concept. Do you know someone who fits the Walking Wounded description? Or do you find yourself in that category?
Help others by encouraging them to grieve in their own ways for the length of time needed. We can learn to carry grief and live with loss without ever arriving at any destination called closure. Healing is a journey, not a place. Visit her online at www. I don't understand any of this.
What does grieving have to do with? Why should grieving have a "roadmap", "journey", "process", "closure", or "healing"? None of these apply, in my experience. Grief is a permanent state, a permanent part of my life, a void and missing and longing and sadness. There is no way out, and nor do I want there to be, unless there is a way to get back the loss.
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