TABLE OF CONTENTS
Aggressive Behavior after a Brain Injury - Walt Kilcullen
Finding a Place to Be - David Wasielewski
Are Men From Mars and Women From Venus When it Comes to TBI -
      By Ksenia Musaelyan (neuroscientist and Beth McQuiston Nuerologist
My Milestones - Rebekah Vander griff LMSW
My Story - Jean-Domonique Bauby
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                 Aggressive Behavior After a Stroke or Traumatic Brain Injury
                                            By Walt Kilcullen
 
After suffering a debilitating stroke, many survivors experience anger. It will vary as to the severity and the intensity, but anger of some degree usually happens.
 
When anger is not controlled and when it becomes part of the survivor’s personality, aggressive behavior can result in uncontrollable irritability, anger pointed at someone such as a caregiver, outbursts seemingly without any reason, or, in some cases, unprovoked violence.
 
Jordan Grafman, PhD, has been researching the cause of this behavior in brain injured patients. While at Kessler Foundation Research Center, he led a study in 2011 which was published in the journal Neurology. He and his team found that two main factors are the cause of aggressive behavior in brain injury survivors: first is the location of the injury in the brain, and second, the behavior is influenced by genetics (pre-disposition). Dr. Grafman stated, “This indicates that the brain imaging and genetic testing can add to what we learn from psychological assessment.”
 
Another study published in Neurology was led by Jong S. Kim, MD, Department of Neurology at Asian Medical Center in Seoul, South Korea. His findings agree with Dr. Grafman’s. His study showed that aggressive behavior after a brain injury is usually related to brain damage rather than distress over their condition. The study of 145 people who suffered a stroke, researchers found that those survivors that experienced anger or aggressive behavior (47 of the patients) had lesions on the parts of the brain responsible for producing serotonin, a brain chemical that moderates behavior.
 
Dr. Kim states, “To my mind, these anger symptoms are generally neurologic but not psychiatric, and doctors should explain this to patients and relatives who are disturbed by these behavioral changes.”
 
Managing this aggressive behavior is important for recovery, the patient’s relationships, and the patient’s ability to work. It is also important for the well-being of the caregivers.  Dr. Grafman States, “Clinicians who see patients with lesions of the prefrontal cortex should inquire specifically about aggressive behavior.” He adds, “patients and their families may benefit from counseling or meditation to manage this behavior. Short-term cognitive behavioral therapy can also be very helpful.”
 
Caregivers may benefit from these tips:
      + Remember that aggressive behavior is part of the effects of the stroke or TBI.
      + Stay calm. Do not overreact to your loved one’s outbursts. Speak slowly
             and softly without raising your voice until your loved one calms down.
      + After you find things that create anger in your loved one, avoid them as much             as possible. For example, if you observe being around a large number of                 people sets him off, avoid that environment.
       + Avoid arguing with your loved one. Redirect her attention to something else.
       +  If you as a caregiver become angry or frustrated, back off and cool down.
           Chances are she will calm down after you step back and remain calm.
       +  Stay safe. If your loved one becomes violent, back away; keep a safe
           distance, and seek help from a family member, a friend, or a neighbor if
           need be.
       +  Find a therapist that specializes in aggressive behavior or at least has
           experience with such patients.
 
Marriages can be strained or even can end after a spouse has a brain injury and exhibits aggressive behavior. It is important that you and your spouse receive counseling. Also, don’t wait for your family members and friends to help with caregiving. Ask them to give you a break by caring for your loved one periodically. And finally, join a support group. Members may have good suggestions to help you.
 

                                          Finding a Place to Be
                                          by  David Wasielewski
 
Recovery from a bran injury and the after-effects, physical and mental deficits, is a process unique to each survivor. For those with permanent deficits this includes coming to accept yourself with new limitations. It means letting go of your pre-brain injury self. It means coming to terms with the losses that go with the new deficits. Participating in favorite activities or even returning to work may not be possible or, if possible, they may no longer be enjoyable.
 
A brain injury survivor who used to enjoy reading may no longer have the focus to follow a storyline or be able to support the complex brain function that allows a decent reading speed, A physically impaired survivor may no longer be able to ride a bike, ski, or even walk short distances without a cane and extreme fatigue.
 
As a survivor I can remember when I was first confronted with the adjustment. It began with a question from a therapist who asked me in an initial interview, “What are your favorite activities?” After experiencing left side hemiplegia from a stroke, I still had favorite activities. I enjoyed volleyball, skiing, and bike riding but could no longer participate in any of these. Ironically, I had a list of hobbies and activities that I loved but could no longer enjoy. How do I answer this question?
 
Any answer that I had seemed pointless and frustrating. Upon examining the situation I realized that I had, in my pre-brain injury life, constructed a place where I felt comfortable. I participated in activities I enjoyed, had a job where I was competent, skilled and valued, had friends to share my experiences with, and a family where my role was clear. I had built myself a ‘place to be’ as had most everyone else I knew. Much of that disappeared in an instant.
 
In order to successfully get through the trauma of the stroke and its aftermath I needed to find a new ‘place’ to be. I needed to reassess my new strengths and weaknesses and find a new ‘place’ where I could be comfortable. This process eventually led me to that new place where my deficits were minimalized or didn’t matter at all. In my adventure I tried to get back on skis and my bike but quickly realized this was not possible. I did, with some effort, get my driver’s license back.
 
I found over time that there are still many things I could do. But where could I go with my altered abilities? I needed to find that place where I could succeed despite my deficits. I was still able to sit, concentrate, read, and converse easily with others. Where were these skilled valued? My wife suggested that I might return to school. This, I realized, was a place where my physical deficits would be minimalized and where I could work to reinvent myself. I returned to college, an environment where physical ability was not a requirement.
 
I found a subject that interested me and settled into an environment where I was somewhat equal, although a bit older than most of the other students. But even the age difference was somewhat minimized when I encountered a number of other ‘non-traditional’ students, some of whom, like myself, had also retuned to campus in order to reinvent themselves due to health issues.
 
The classroom and campus became my new ‘place to be.’ This was and remains an environment where my ability and experience are somewhat valued. I was on equal footing with the other students who shared the common interest and goal of reinventing themselves. I can, for the most part, participate equally and even excel with the other students.
 
By exploring and examining the situation I was slowly able to find the virtual blocks I needed to build a new ‘place’ for myself. I found that the stroke offered me the chance to reinvent myself.
 
Certainly, school is only one of the options that exists for brain injury survivors with deficits, but survivors need to be willing and supported as they explore their options in order to find that new ‘place’ where they are comfortable. I have found that this process of looking for something new lessens the overwhelming feeling of loss that can consume a survivor. Concentrating on a new challenge helps replace sadness and loss with hope and challenge.
 
It distracts the survivor from depression and creates an adventure. Some survivors will have to try out several options before finding an appropriate ‘place.’ But the point is to keep exploring until you find your place. For some it may be as simple as finding a support group where they are accepted and valued for their support and friendship. For others it may be finding talents they have neglected as they built their busy pre-brain injured lives. I have seen the post brain injury adventure lead survivors in some unexpected directions.
 
As a brain injury survivor, I left behind a career as a business logistics consultant and now run a stroke support group and do peer counseling. The successful accountant may, after a brain injury, find time to pursue an interest in music even though she cannot read or write. The graphic artist forced to quit his job may discover a talent for joke and storytelling that is appreciated when the brain injury support group meets. The aphasic medical student discovers a new career as an aphasia advocate and motivational speaker.
 

         Are Men From Mars and Women From Venus When it Comes to TBI?
       By Ksenia Musaelyan, Neuroscientist and Beth McQuiston, Neurologist

“This article originally appeared in Vol. 14, Issue 3 of The Challenge!, the quarterly newsmagazine of the Brain Injury Association of America. It is reprinted with the written permission from the Brain Injury Association of America, Inc. c2021. Copies of the original issue can be downloaded at www.biausa.org.”
 
Gender differences in traumatic brain injury (TBI) have attracted both public and medical research attention in recent years. We are at the beginning of this journey with much research being undertaken to prevent, diagnose, and treat TBI using a comprehensive and individualized approach. Overall, TBI occurs in men more often than it does in women, and until very recently, has been perceived as a “male injury” as it may occur in those playing high-contact sports or in careers that are more physical in nature. However, when looking at specific age or occupation groups, the sex difference in the risk of sustaining a TBI disappears. For example, men and women over 75 years of age are equally likely to suffer from this condition. Moreover, it has been shown that some groups of women are, in fact, at higher risk of sustaining a TBI than their male counterparts. For example, female athletes in collegiate sports with similar rules as the male teams, such as soccer, basketball, and baseball/softball have a higher rate of concussion.
 
The diagnosis of mild TBI or concussion is not a trivial task, and many concussions go unrecognized, which makes the estimation of the occurrence in men and women more complicated. Currently, clinicians rely heavily on subjective symptoms and clinical exam findings to assess potential injury. While this information can be useful, objective tools would help to paint a more complex picture. Fortunately, new technology is under development and may achieve some of these goals. For example, blood tests under development by Abbott may detect proteins in the blood which are indicative of brain injury. Measuring such proteins may provide additional, objective information about the presence and severity of the injury to the clinician and patient.
 
Sex differences are not related to the diagnosis itself but extend into the way men and women experience and recover from TBI. It has been shown that women are more likely to feel the long-lasting and chronic effects of injury. For example, several studies have demonstrated that women may be more susceptible to depression in the first month to one year post injury. Others have reported that women may have more nausea and sleep disturbances and have more headaches following injury. In addition, female athletes have been shown to have more post-concussion symptoms and may require a prolonged recovery time in sports such as soccer and basketball.
 
Although women may suffer a higher rate of injury symptoms, they may be less likely to die or have a disability from a TBI. They are also more likely to return to work, school, or sporting activities than men sustaining similar injury. Of note, such results usually come from studies analyzing thousands of patient records rather than interviewing people individually, which can introduce differences related to the way TBI survivors report and deal with their symptoms.
 
Biologically, gender differences may play a role in TBI recovery. In women, post injury factors such as higher pressure inside the skull and greater tendency for brain swelling may lead, in some circumstances, to worse outcomes after a TBI. At the same time, protective mechanisms such as a higher number of connections among certain brain regions and a higher resiliency of those connections can protect women from developing post-concussive symptoms in certain types of injury. The ability to accurately and objectively monitor brain injury is key to a better treatment and recovery from such symptoms. This is another area where measuring blood proteins which reflect how the injury unravels, can substantially improve patient care.
 
Interestingly, some female sex hormones, such as progesterone and estrogen, are believed to be protective against TBI and are believed to help patients, both men and women, to achieve better recovery. It is important to remember that men also produce these hormones albeit in smaller doses, and it is thought that they play important roles in body growth and development. Conversely, hormonal fluctuations can lead to increased risk depending on the phase of the menstrual cycle during which the woman is injured. Progesterone and estrogen have now been closely linked to brain health – so much so that some experts believe that these hormones also play a role in depression and anxiety.
 
The evidence for protective effects of progesterone is compelling enough to warrant several clinical trials of treatment with progesterone-like compounds, with some finding and others not finding improved recovery after TBI. Why would studies have such conflicting results? Hormonal regulation is a highly intricate process and more research is needed in this area. At the same time, accurate selection and monitoring of patients can play a key role in the outcome of trials evaluating the effect of novel treatments like progesterone. This is another area where monitoring injury-indicative blood proteins to track the progress of patients taking part in new treatment trials may facilitate their success and lead to a speedy implementation of new effective interventions into clinical practice. This would ultimately mean better recovery and quality of life for people sustaining a TBI.
 
Brain injury is a complicated problem affecting much of the population. To best help all patients, a true team approach is needed. A number of collaborations between patient advocacy groups such ad the Brain Injury Association of America, governmental agencies, industry, academia, and the military are underway with many promising results on the horizon that include more information about sex-based differences. This team approach, including focus on all genders, will be critical in helping patients live their lives to the fullest.
 
            References available at biausa.org/TBI and Gender