Been busy of late - sorry about the sermon
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Yours
Doc Spock
"Suppressed neurotransmitter function is a key element in cognitive and emotional difficulties for patients who have experienced mild traumatic brain injury "
(a.wright May 2009 ref 0003)
Background
Patients who have experienced a mild traumatic brain injury will experience a number of changes, both to the physical functions of the brain and sometimes, psychological changes as well.
Interestingly the extent of the injury is no direct predictor for the extent of the damage or indeed how long it may take to recover. Recovery periods of several years are not uncommon, and whilst 99% recovery is possible, seldom do the patients claim a full 100 percent recovery.
Cognitive and emotional difficulties
The cognitive problems can demonstrate in a number of ways with immense variation in both scope and extent. Common complaints would list short-term memory, brain fatigue, plus stress. Also poor motor function and coordination or general “slow� thinking are also factors.
The emotional difficulties are rather harder to define. In one sense the change of life post injury may itself impact on emotion. Circumstances of life may change the mind state.
It’s also the case that the recovering patient may experience different mind states during the recovery phase. The Human body is programmed to survive, and this can lead to very primary survival type mind states, changing both emotional and social interrelations. Interestingly there are some common responses from patients.
Many would describe feelings of anger and frustration, and many experience depression.
Some mention a life in black and white (rather than the former “colourful� existence)
There is an interesting clue here that it possible for the “anger� emotion to work but the “pleasure-reward� function of the brain may well be diminished.
What is brain fatigue?
When the human body is physically tired or exhausted, it is possible to observe various changes in the physical biology of the body. The patient might be short of breath, maybe with low blood sugar levels and possibly additional lactic acid in the muscles. The patient would express the condition as tired or exhausted – and the biological evidence would confirm this.
Brain tired is quite different. There is no doubt that the patient feels exhausted, and almost certainly would have to rest. However the normal measurements of blood sugar and oxygen would not show any form of fatigue. In other words the patient feels tired but in terms of normal physiology would not be measured as tired. Sensations are real enough and it is quite possible to push so hard that the body would actually collapse (similar to a fainting fit?) The brain may simply have out consumed its supply of key nutrients and the body production cannot easily, quickly, replenish the supply.
Brain fatigue is a circumstance brought upon by brain overload where the brain is being required to attempt to handle too many demanding tasks for too long. Stress is a key component here. In short it is an overworked brain that needs to rest – it is very hard for the patient to distinguish between “body tired� and “brain tired.�
On the bright side it does seem to the brain will recover from overload rather more quickly than human muscles/blood sugar/oxygen levels.
Neurotransmitter function/malfunction
Human brain is an immensely complex instrument that at a base level functions by one part communicating with another utilising key chemical components. The communication is by neurotransmitters, which use dophamine, GABA, norepinephrine, enkephalin, endorphins, and seritonin to generate the signals. Just about everything in the human body functions moves, thinks, and feels as a consequence of the interaction of these chemical components. The human body manufactures its own supply from amino acids from the dietary intake. Given the different parts of the brain it is vital in order to function fully, and completely, that the interbrain communication functions as it should.
Some substance abuse is centred on stimulating key neurotransmitters to create feelings of extreme highs or euphoria while others create illusions and altered mine states. Recovering abusers often express that life is never quite the same afterwards. There are studies that indicate that the neurotransmitter function is permanently suppressed as a result of the substance abuse.
The recovering traumatic brain injury patient may experience lack of coordination sometimes even mild spoken or written dyslexia. This indicates that the coordination of the different parts of the brain is not working as well as it was. This could be to do with a rewiring process. It is thought that the brain is learning new pathways to complete tasks and that this relearned state is still comparatively young and not yet fully functional. However in addition to the obvious cognitive malfunction there are also fatigue and emotional issues to consider. The hypothesis here is that the neurotransmitters are malfunctioning due to a shortage of key vital bio/chemical components. They are not damaged as such, but are left without the vital nutrients to work effectively
Similarities with other conditions
Interestingly there are many conditions that seem to show the similar symptoms.
Parkinson’s disease (which is known to include neurotransmitter damage) in the early stages seems show very similar properties and symptoms to the traumatic brain injury patient.
In Parkinson’s the actual transmitter is thought to be permanently damaged, but would a functioning transmitter, which had no chemical resource (fuel) give the same effect?
Clearly with Parkinson’s the condition then extends and deteriorates whilst the TBI seems to improve.
Also there is similarity with the recovering drug user – particularly regarding emotional states. The concept of living life “without colour� – i.e. emotionally flat with few highs seems to show similar mind states in these ex users/abusers
Why does the post injury Brain consume more?
In the TBI survivor just about all mental/physical tasks now take more effort. This may well be a reflection of the rewiring that the brain has had to do to retrain body/mental function. If it really is the case that new and longer pathways have now been found. It is not unrealistic to imagine greater consumption of the vital nutrients that allow these neurotransmitters to function. Basically the brain is working harder and in consequence is using more fuel.
How is it possible to experience emotions such as anger and frustration but not joy?
The human body at its base level is a survival mechanism and is programmed as such. Studies have shown that when dophamine is in short supply the body at some level makes a conscious decision to allocate this vital nutrient on a priority basis. Ultimately the basic priority is fight or flight
So all functions around this – including anger (which links to fight) would seem to get priority over secondary and other functions – which might include love joy happiness and friendship.
These are important functions–but are not necessarily life-threatening. Thus paradoxically in a low neurotransmitter function situation, it is possible to experience extreme anger but not euphoria or happiness. This may well explain a medical condition called Anhedonia (which is sometimes linked to a depression or an dophamine deficiency?) Note that depression can cause poor dophamine levels, and poor dophamine levels can cause depression – it can be a reinforcing cycle with no clear indication which was the initial cause. There are documented studies that can show a link between Anhedonia and poor inter brain communication. Brain mapping exercises clearly showed inter brain links were not as good amongst depressed patients.
Frustration is a common cause of the condition – can most patients remember, “how they were� What they could achieve pre trauma – but are faced ongoing with setbacks to remind them almost daily that they are “not fixed yet�. Sadly this emotion seems to function very well.
Can we measure this brain chemistry imbalance?
Within certain medical centres (abroad) there are extensive claims about measurement performed either from blood or urine samples. It is not quite that simple, it is currently almost impossible to determine the internal brain chemistry of a living human being. Also it is not completely clear exactly how much, or what composition, a “correct� brain should have.
These are undefined areas, with much research, but little hard evidence. This may explain the current levels of speculation around the issue.
Some experiments on depressed patients has shown lower “interbrain� communication,
but the cause was not successfully identified .
So how does “brain exercise� help?
Brain exercise if correctly applied allows the new relearned pathways to be exercised.
As these pathways work longer and more often, they become stronger and more efficient. In the initial stage there may be greater fatigue but mid-long term the benefits are very useful.
Firstly as the patent becomes generally more proficient with greater stamina, the fatigue sensations will reduce. Short-term memory may improve and thinking processes that require inputs from many parts of the brain may function better.
Secondly if the brain does not have to work so hard with the motor/coordination function – it will have greater resource for mood and pleasure reward systems i.e. the patient may “feel� better. This is because the motor/coordination function would sit in a higher priority if there were a shortage of resource (e.g. survival), than the emotional “well being�.
Finally of course as the patient’s function improves – the patient’s confidence will grow while the frustrations associated with the deficits may actually reduce.
So clearly brain exercise is recommended – but care must be taken to move at a pace that the recovering patient can cope with – too much, too soon, may simply overwhelm, and cause further setbacks.
Sources of Neurotransmitter fluids
The human body manufactures its own supply of these vital fluids from key amino acids from the dietary intake (mainly phenylalanine and 5HTP). It is unclear if the body can store these in any way, or if it has any use for any overproduction – most studies seem to suggest any overproduction is simply reabsorbed.
Possible solutions
It is not clear if it is possible to assist the body to create more of the key fluids that are required. One possible solution is to ensure that the body gets a regular and ongoing supply of the key amino acids that are the key building blocks for production. A diet rich in phenylalanine and 5HTP would seem to make sense, so that the body does have the means to produce.
There are many foods that would provide these basic components. A diet consisting of (but not exclusively) Bananas, Beets, Blue-green algae, Brown, rice, Cheese, Fennel, for Seritonin
With Apples, Beets, Blue-green algae, Celery, Chicken, Cucumber, Fish, Green leafy vegetables, Hone, Cheese, Sweet peppers, Tofu, Watermelon, for Dolphamine
While for Phenylalanine (the basic building block for many amino acids) most of the above plus milk, eggs, and most nuts. 5HTP is linked to cheese and most white meats. This is neither an extensive list nor does it require a major lifestyle change to implement.
There are various dietary supplements, that the healthcare industry worldwide makes some extensive claims for – but there are questions surrounding the absorption of such supplements when not being delivered in a food format. Also in many cases the actual chemical reactions to create the amino acids are quite complex requiring the presence of other elements to create a successful outcome. In a sense a natural diet (real food) approach would seem to make more sense?
A third possible route is to introduce MILD serotonin reuptake inhibitors (SSRI`s). I would stress the “mild “part for a number of reasons. Firstly there are indications that long-term exposure to SSRI`s can actually reduce the bodies capacity to produce its own serotonin.
Secondly given all the other issues that the TBI patients have to live with, an excessive stimulant may well cause more problems than it solves. Problems either with coordination, fatigue, or anger and frustration, may be exaggerated by too strong a stimulant. So I would suggest only “mild� stimulants the best course. To some degree it will depend “where� the patient is on the recovery path as to if this part of the exercise should be attempted at all.
What about a conventional therapy approach
Conventional therapy certainly has a place in the recovery process. The patient will have many issues to come to terms with, from the change of life to all losses both physical and mental. However if it truly is the case that there are functional changes within the brain or its chemical balance, it is surely unlikely that a therapy “only� approach will be 100% successful.
It would seem to be most effective when used in conjunction with other therapies. it does follow that for a patient proactively pursue some of the other strategies mentioned here; that the patient were already need to be in a positive state of mind. This is unlikely to be the case unless the groundwork has already being put in place, by therapy. It is also the case that it is probably not a good idea to retain the drug therapies beyond a certain time. To some degree the therapy support may well be able to assist with the withdrawal of the medication.
Conclusion
The recovery process may take many years, and will need to be at a pace that the individual can cope with. However there are indications that a more proactive approach to the brain chemistry will assist the pace and extent of the recovery. The diet aspect should not be ignored, and is comparatively simple to implement. On balance a changed diet with short-term, mild, SSRI intake would seem to be the best course supported by ongoing mental exercises and therapy (CBT).
