A case of "borrowed identity syndrome" after severe traumatic brain injury.

BACKGROUND: It is well known that traumatic brain injury often changes the way the patient perceives reality, which often means a distortion of the perception of self and the world. The purpose of this article is to understand the processes of identity change after traumatic brain injury. CASE REPORT: We describe progressive deterioration in personal identity in a former physician who had sustained a serious head injury (1998), resulting in focal injuries to the right frontal and temporal areas. He regained consciousness after 63 days in coma and 98 days of post-traumatic amnesia, but has since displayed a persistent loss of autobiographical memory, self-image, and emotional bonds to family and significant others. Qualitative 'life-story' interviewing was undertaken to explore the mental state of a patient whose subjective, "first person" identity has been disengaged, despite the retention of significant amounts of objective, "third person" information about himself and his personal history (though this was also lost at a later stage in the patient's deterioration). Identity change in our patient was characterized by a dynamic and convoluted process of contraction, expansion and tentative balance. Our patient tends to cling to the self of others, borrowing their identities at least for the period he is able to remember. Identity is closely connected with the processes of memory. CONCLUSIONS: The results will be examined in relation to the microgenetic theory of brain function. The brain mechanisms that may account for these impairments are discussed. Findings from this study have important implications for the delivery of person-focused rehabilitation.

Early neurorehabilitation in a patient with severe traumatic brain injury to the frontal lobes.

BACKGROUND: It seems to be generally believed that early neurostimulation after severe TBI is useless or even harmful, and neuropsychological intervention should not be initiated until the patient is medically stable. On the other hand, the unstimulated brain can incur irreversible damage. The purpose of the present study is to assess the impact of early neuropsychological rehabilitation on a patient with an extremely severe TBI. CASE REPORT: The patient, a 32-year old male, suffered a massive cranio-facial injury with significant loss of tissue in the right frontal lobes after being struck by a tram. Beginning two weeks after injury, after pharmacological coma, he was attended on a daily basis by a neuropsychologist and a neurolinguist, with the active assistance of his family, when he was still in critical condition and essentially without logical contact. By the time he returned to Scotland 4 weeks later, he was sitting up, writing complete, sensible and grammatical sentences, and making rapid progress every day despite the development of hydrocephalus. Over the course of neurorehabilitation, most of MF's cognitive dysfunctions resolved. Six months later, however, hydrocephalus was increasing and the patient was showing severe frontal syndrome. A personalized version of Community Based Rehabilitation was applied. After two weeks of intensive treatment considerable improvement was achieved and frontal syndrome was reduced. CONCLUSIONS: The present case suggests that the prevailing views regarding the inadvisability of early neurorehabilitation in the acute phase after TBI should be reconsidered.

The autistic mind: a case study.

BACKGROUND: Despite years of intensive research, there is much about autism that remains theoretically and practically difficult to understand. There are presently three main theories: (1) defect of theory of mind, (2) executive dysfunction, and (3) lack of central coherence, i.e. an inability to integrate sensation and behavior into complex and sensible wholes. CASE REPORT: The patient, Damian S, born 1993, was diagnosed in early childhood with profound autism. He has been closely observed longitudinally by the first author, who is his therapist. Despite the absence of noticeable improvement in standard psychometric tests, he has shown considerable clinical progress. However, he continues to have difficulty in making and maintaining contact with others: he converses spontaneously only with his father and his teacher, and interacts with other persons (including his mother) only in the presence of one of these two persons. However, he has learned to use a computer to communicate. Samples of dialogue are provided to help illuminate how he thinks. CONCLUSIONS: Despite his profound autism, Damian displays awareness of and concern for the thoughts and feelings of others. He is also able to solve problems. On the basis of this and other observations, the authors suggest that the "central coherence" theory better explains the available observations and data.

Neuropsychological diagnosis and treatment after closed-head injury in a patient with a psychiatric history of schizophrenia.

BACKGROUND: Despite recent interest in the brain/mind problem and possible organic correlates of mental disease, relatively few case studies have examined the problem concretely. The present paper describes a 66-year-old male patient with a long history of schizophrenia, whose psychotic symptoms displayed qualitative and quantitative changes after a closed-head injury. CASE REPORT: After a very disturbed childhood and youth, including several jail terms, the patient was diagnosed with schizophrenia in the early 1960s and frequently thereafter hospitalized. Visual hallucinations were the dominant symptom, and art therapy provided some relief, which led to a successful artistic career. In 1989, while actively hallucinating, he suffered a mild TBI in a pedestrian accident. Despite findings of organic dysfunction, he did not receive full neuropsychological diagnosis and treatment until four years later, when he presented with symptoms of perseveration, hemispatial neglect, and disturbances of working memory. The patient then received an individual program of neuropsychological rehabilitation, while his treating psychiatrist gradually withdrew psychotropic medication. After a year of therapy there was marked improvement of both neuropsychological and psychiatric symptoms. At the same time, he began to paint in a completely different style. CONCLUSIONS: The case described here shows that the pathomechanisms of schizophrenia and neurobehavioral disturbances resulting from organic brain damage are not after all unrelated. Microgenetic theory can provide a basis for explaining the course of symptoms in this and similar cases, as we re-think the brain-mind relationship.

Post-traumatic stress disorder in Polish stroke patients who survived Nazi concentration camps.

BACKGROUND: Many persons who survived Nazi concentration camps are now in advanced age, so that rehabilitation centers in Poland are seeing increasing numbers of such patients, especially after strokes. In many cases, the process of rehabilitation is severely hampered by Post-Traumatic Stress Disorder (PTSD), while the neuropsychological consequences of the stroke itself often evoke traumatic memories and simultaneously disorganize or destroy the patient's previous coping mechanisms. The present study describes the program developed by the authors for concentration camp survivors in post-stroke rehabilitation, including the use of art therapy and specially prepared films to help the patients cope with PTSD. MATERIAL/METHODS: The experimental group (KL) consisted of 8 such patients (4 men, 4 women, average age 79.1+/-4.28) with mild post-stroke aphasia who went through the PTSD program, while the comparison group (C) included 8 post-stroke patients, matched for age and gender, who were not concentration camp survivors and showed no premorbid symptoms of PTSD. All subjects were tested at baseline and again 3 months later, using structured interview and observation, self-rating scales for three basic negative emotions (anger, anxiety and sadness) and the Frustration and Aggression Test for the Disabled. RESULTS: The results showed significant differences between the groups at baseline, while at follow-up the differences between groups had changed in both extent and distribution. CONCLUSIONS: Qualitative analysis of the results allows for some important observations about the etiology and course of PTSD in these persons.

Reintegrating space and object representations in patients with hemispatial neglect: two case studies.

PURPOSE: This article examines the effectiveness of differentiated rehabilitation programmes for patients with two distinct types of hemispatial neglect: body-centred and object-focused. We hypothesized that patients with body-centred neglect would respond to motor-control programmes designed for patients with limb apraxia, while those with object-focused neglect would require visually oriented therapy. MATERIAL AND METHODS: The article describes the rehabilitation of two patients treated by the authors 6-9 months after right-hemisphere infarct. Both showed significant left-sided hemispatial neglect: body-centred in one case (patient BC), object-focused in the other (patient OF). A modified AB-BA experimental design was used, where A represents visual training, and B is spatio-motor training. For patient BC, the sequence was A-B; for patient OF, B-A. Neglect was measured using standard tests for neglect and the analysis of drawings made during therapy by both patients. RESULTS: As hypothesized, patient BC showed no progress after conclusion of programme A, while after programme B she showed virtually no lingering neglect. In the case of patient OF, the results were exactly reversed. CONCLUSIONS: Body-centred neglect is essentially a defect in space formation, while object-focused neglect is a disorder of object formation. The patients described here both benefited from neuropsychological therapy for neglect, but not from the same programme.

Disturbances of speech and language in patients aroused from long-term coma subsequent to traumatic brain injury.

Background. The purpose of this study was to characterize the speech and language disturbances seen in patients with traumatic brain injury aroused from long-term coma at the Rehabilitation Clinic of the Bydgoszcz Academy of Medicine. Material and methods. The research covered 94 patients (30 women, 64 men, average age 34.7). Speech and language disturbances were diagnosed with basic neuropsychological batteries and authorial methods, and classified as akinetic mutism, global aphasia, sensory aphasia, motor aphasia, dysarthria, or dysphonia. The patients were examined 3 times: at admission, after one month, and after two months. Results. The patients displayed various speech and language disturbances. In the first examination, 47 persons (50.0%) presented with dysarthria. Post-traumatic aphasia was seen in 28 persons (29.8%). Akinetic mutism was somewhat less common (12 persons, 12.8%) and dysphonia least common (6 persons, 6.3%). In the second examination there were numerous shifts between groups, and 15 persons no longer had any disturbances (16.0%). These trends continued in the third examination. Dysphonia was seen in 4 persons (4.3%), akinetic mutism in only 3 (3.2%). 23 persons (24.5%) did not show any speech and language disturbances. Conclusions. Patients aroused from long-term coma display various speech and language disturbances. A significant number have dysarthria and/or aphasia, somewhat fewer have akinetic mutism. Dysphonia is also seen. Mutism often resolves spontaneously, as does dysphonia, while the symptoms of aphasia and dysarthria are more persistent.

An evaluation of executive functions in sportsmen after traumatic brain injury.

Background. A particularly difficult problem in the rehabilitation of patients with closed-head injuries (TBI) is executive dysfunction, i.e. difficulty in the transition from thinking to acting. The goal of this study was to evaluate the impact of premorbid sports background on the outcome of rehabilitation oriented towards executive functions.
Material and methods. This retrospective study included over 80 TBI patients treated at the authors' rehabilitation centers from 2000 to 2003, using the same program. The experimental group (E) consisted of 9 persons actively involved in sports before their accidents. The controls (group K) included 9 TBI patients not involved in sports prior to the accident, matched to the patients in group E for age, sex, and severity of coma. In addition to clinical interview and observation, we used the Clinical Test of Executive Functions and the Neurolinguistic Test of Attention as outcome measures.
Results. Our results indicated clearly that patients who had been active in sports before injury showed significantly better results in both outcome measures, though the advantage was somewhat greater on the Clinical Test of Executive Functions.
Conclusions. All the TBI patients we studied presented at baseline with serious executive dysfunction. The program of neurorehabilitation we applied showed good effects for the patients in both groups. However, those who had previously been active in sports achieved significantly better outcomes than those who had not. In planning and improving rehabilitation programs for TBI patients the possibility of a sports background should be taken under consideration.

The course of vision disturbances in a patient with the MELAS syndrome.

BACKGROUND: This article describes the neuropsychological and ophthalmic symptoms presented by a patient with MELAS, a mitochondrial cytopathy. This rare disease is characterized by a remitting-relapsing course against the background of a slowly progressive degenerative process. CASE REPORT: The patient is a 22-year-old Polish female, with initial onset of symptoms in 1994; the clinical diagnosis of MELAS was established in 1998, and confirmed in 2000 by the discovery of a novel mtDNA mutation. Her visual acuity fluctuates from near-normal to near-blindness, often changing dramatically within a matter of weeks; the visual field has more or less steadily narrowed to lunate. Visual evoked potentials show sporadic disturbances, while the nerve fiber layer shows significant attenuation. The evidence points to a complex etiology, involving both cortical damage and attenuation of the optic nerves and neural pathways. A similar two-phase pattern--episodic disturbances with rapid spontaneous recovery against a background of progressive deterioration--occurs in neuropsychological testing, which reveals progressive dementia and episodic aphasia. CONCLUSIONS: The peculiar pathomechanism of MELAS results in simultaneous insults to various parts of the central and peripheral nervous systems, creating the complex and highly variable pattern seen in this patient. In clinical practice care should be taken not to overlook the possible significance of such a pattern appearing in various systems and on varying levels.

Active and passive executive function disorder subsequent to closed-head injury.

BACKGROUND: Executive dysfunction is one of the most destructive sequelae of closed head injuries (CHI), often impeding or even preventing the patient's return to normal functioning. On the basis of extensive clinical testing of patients with neurobehavioral disturbances resulting from CHI, the authors propose a new typology of executive dysfunction based on the primary behavioral distinction between active ('acting without thinking') and passive ('thinking without acting') forms of executive function disorder. MATERIAL/METHODS: Two patients were selected for detailed presentation. Both present with mild to moderate motor and cognitive symptoms resulting from closed head injury. The medical histories of the two patients are similar (educated professionals, mid-40s, married with children, injuries suffered in a traffic accident, 2 months in coma) except for the location of focal injuries. RESULTS: Despite considerable progress in rehabilitation, the extent of functional disorder is disproportionately large in comparison to the degree of objective disability measured by standard instruments. It is suggested that the reason for this disparity lies in executive dysfunction. In particular, a model for executive functioning will be presented to explain why and how selective destruction of particular anatomical/functional components leads to the behavioral consequences known as 'executive dysfunction'. CONCLUSIONS: Executive dysfunction is a distinct clinical syndrome which occurs in at least two distinguishable varieties, active and passive.

Differential diagnosis of frontal syndrome in patients with closed-head injuries.

Background. A common sequela of head injury is "frontal syndrome", consisting in characteristic neurobehavioral disturbances. However, there is no ecologically valid research tool that would clearly indicate the presence of this syndrome. The goal of this article is to evaluate the authorized the Polish version of the Frontal Behavioral Inventory (FBInv), used to differentiate fronto-temporal dementia (FTD) from other dementias. Material and methods. The research involved 95 patients treated at the centers represented by the authors, divided into 3 groups: CHI, consisting of 39 patients with traumatic frontal lobe injuries; FTD, consisting of 28 patients with fronto-temporal dementia; and a control group of persons with post-traumatic depression without injury to the frontal lobes. The results were based on data obtained from caregivers in 24 categories of patient behavior covered by the FBInv. Results. We found important differences in total scores between patients with frontal syndrome from groups CHI and FTD, as against patients with post-traumatic depression. There are also noticeable differences between patients in group FTD and group CHI in terms of scores on particular test items. Conclusions. The FBInv in the authorized Polish version is both sensitive and specific in measuring neurobehavioral disturbances occurring in patients with post-traumatic damage to the changes in the behavioral and personality of these patients with the passage of time since injury or onset should be the topic of further research.