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The Real Trauma of TBI

 News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences

Understudied and underdiagnosed, survivors find clinic life-changing

“They’re nobody’s baby.”

Psychiatrist Vani Rao says that of more than a few of the people who see her after their auto accidents, falls or assaults resulted in brain damage. Rao heads the Brain Injury Clinic on Hopkins’ Bayview campus. At some point, losing consciousness and/or memory got patients rushed to an emergency room, then surgeons were quick to address what they could. “But after rehab and followup visits,” Rao explains, “they’re often left on their own. Nobody ‘needs’ to see them any more because, supposedly, their acute problems have been tended to.” 

Dr. Vani Rao

Dr. Vani Rao

For many of the 1.4 million annual survivors of traumatic brain injury (TBI), however, that’s when the real trauma begins (see story, below). “Neurological effects usually improve or become stable with time,” Rao says, “but emotional, mood and behavior disorders can persist over months or years.” Anxiety, apathy, a whittled attention span and other cognitive and psychiatric problems aren’t rare. Hair-trigger anger or unbridled bluntness, for example, redefine some survivors’ personalities. “Before long, their families’ patience fades,” Rao says. “Then everyone suffers.” TBI raises the risk of death by suicide to four times that of the general population.

Because the need for therapy and heightening family understanding is great, Rao set up the clinic some six years ago, as part of Hopkins’ Community Psychiatry program. And because TBI is “understudied and underdiagnosed,” Rao has found herself one of few U.S. psychiatrists working to define its mental effects and clarify the problems that follow.

How does the clinic help?

A daughter of Hopkins Medicine, Rao relies on the tested, conceptual approach to diagnosis and therapy that mentors Paul McHugh and Philip Slavney laid down in The Perspectives of Psychiatry. She first addresses the biology. “Some problems clearly stem from the injury,” she says. Frontal cortex damage or short-circuited deeper brain circuits can make patients impulsive or bring on major depression. Antidepressants can ease the latter, which affects a third to a quarter of TBI patients. Other drugs may tighten attention, memory or executive function.

“But to say it’s all biology accentuates the disease at the expense of the person,” Rao says. There are psychosocial aspects: TBI’s dramatic onset, for example, often swamps patients’ coping abilities. It widens hairline cracks in family relationships. And patients’ sudden drop in self- awareness—common in prefrontal injury—distresses everyone.

So Rao assesses the new vulnerabilities and ways patients respond to what life hands out. Learning who the ‘new’ person is suggests ways to cope. “We help patients see that they’re easily frustrated, for example, and teach ways to avoid situations that play on that.” The clinic’s two therapists motivate and offer the support it takes patients to change.

Targeting troublesome behavior—that within patients’ control—is also useful, Rao says. Though not a direct outcome of injury, abnormal social or sexual behaviors may surface as inhibition fades in impulsive patients. Suggestive remarks or inappropriate touching can really send life downhill fast, she says, especially when a patient’s self awareness is weak.

And, last, says Rao, her staff delves into patients’ life stories for a true perspective. From that vantage point, she says, therapist and patient look down together on past and present and, almost dispassionately, choose a good path or, “rescript” the story.

“People need to know their problems are common after TBI, that they’re not a sign of moral weakness, and that they can become whole in a new way.” 

For information: 410-550-0019.

See also Catching Terry Cumming.

For more information go to the .Brain Injury Clinic.

Winter 2007 Index | Hopkins Newsletter Archive