|Posted by Margaret Donohue on June 16, 2019 at 3:00 PM||comments (73)|
The vast majority of neuropsychologists publishing research on brain injury in the United States appear to have some connection to insurance companies. So the research they tend to publish minimizes the impact of repetitive brain injury, the apparent delay in symptom onset from time of injury, the impact of whiplash without loss of consciousness and correlation to brain injury. What they focus on is estimates of effort and use a population of individuals simulating brain injury in college students as a "deceptive group." This creates incorrect data about brain injuries that are then believed by physicians, neurologists, neuropsychologists, and psychologists in general.
1. Brain injuries completely recover in a few days to a few months. All brain injuries such as concussion completely resolve in 6 months.
2. Low impact crashes with whiplash only do not result in concussion or brain injury.
3. People complaining of ongoing symptoms are either faking, exaggerating, have a mental illness, or something else is wrong besides their brain injury.
4. Neuropsychological testing for brain injury requires multiple measures of malingering, effort and attempts to fabricate their presentation.
1. A lot of brain injuries with mild concussion completely recover with no residual symptoms, but about 20% have ongoing symptoms.
2. Following an injury or accident symptoms can occur as long as 96 hours post accident or injury.
3. Neuropsychological testing is expensive. The use of testing time to document exaggeration or effort is better spent looking at functional ability and limitations. The testing should match the symptoms, and be consistent with the history and medical records. If the testing doesn't match the history THEN do testig for malingering and effort.
4. Brain injuries cause psychological difficulties. In addition if someone has pre-existing depression, anxiety, or other symptoms of mental illness the brain injury will complicate coping and response to treatment.
5. A very small percentage of people that have sustained a brain injury will go on to develop a malignant leision in that area of the brain or an autoimmune disorder. We are currently researching that population. If you or a family member has developed an autoimmune disorder or any form of brain cancer after a traumatic brain disorder or concussion, I'm interested in hearing from you. Please drop me an email Donohuema1@me.com.
|Posted by Margaret Donohue on February 28, 2016 at 8:50 AM||comments (36)|
In 2006 I and a colleague stood up in an auditorium in San Jose at a California Psychological Association convention and spoke about what it was like to have a head injury, and how the research, done mainly by psychologists working for insurance companies and personal injury attorneys, was flat out wrong.
In 2006 basic information about concussion included the following INCORRECT information:
We’ve come a long way. Here’s what we know now:
It’s 2016. Here’s what we need to know:
Our office evaluates people to provide information on neuropsychological functioning. If you need an evaluation feel free to contact us at 818-389-8384.
|Posted by Margaret Donohue on December 13, 2015 at 11:55 PM||comments (50)|
Migraines are a type of vascular headache causing a variety of responses to inflammatory pain in and around the lining of the brain with symptoms of acute nausea, vomiting and severe pain. They are different from tension headaches, cluster headaches, rebound headaches, post-concussive headaches, sinus headaches, headaches from hypertension, headaches based on changes in blood sugar, abdominal migraines, hormone related headaches, chronic progressive headaches, and mixed headaches in addition to rarer forms of headaches.
Migraines cause the hands and feet to be cold. They may cause a wide variety of neurological symptoms such as loss of speech, problems with vision, visual and auditory hallucinations including hearing music, and olfactory hallucinations. They can be triggered from a variety of foods, medications, hormonal conditions, stress, genetic predisposition, and environmental conditions. It's important to differentiate migraines from other types of headaches and other medical conditions.
There are a wide variety of treatments for migraines. These include lifestyle changes to reduce stress, adding meditation or yoga, physical therapy, massage and ensuring adequate sleep and exercise. There are lifestyle changes to eliminate triggers for migraine such as eliminating caffiene or other migraine triggering foods or drinks, changing diet to a less inflammatory diet, and changing sleep and wake patterns. There are medications taken at the start of a migraine to lessen the intensity and severity of migraine, and medications taken to prevent migraines from occurring. In chronic migraine botox can be used.
If you are having chronic headaches feel free to contact me for evaluation. 818-389-8384.
|Posted by Margaret Donohue on October 11, 2015 at 1:50 PM||comments (36)|
It was 1985. I lived in Panorama City and the man that followed me through the security gate was intent on robbing me. I hit the back of my head on concrete and sufferred a concussion. My glasses were broken into my face when he hit me. I didn't notice anything was wrong apart from the bruises. It was about a month before I noticed my sense of smell and taste were off. It was almost 6 months before I realized I didn't really recognize faces. People looked like people. I wnt to work. I interacted with people. Everything seemed fine. Then I noticed people at work were changing clothes often. Like every hour or so. As I moved around the office complex I'd see someone, then an hour or so later I'd see them again but their clothes were different. Hmm.
So one day I went to Terry and asked her why she was changing her clothes so often. "Huh? I'm not." She said. "But earlier today you were wearing a blue jacket over some slacks, now you're in a yellow dress." I said. "Jean has on a blue jacket. She's worn it all day." "Jean? That was Jean?" So I started trying to keep track of all the people that were changing clothes. No one was. I just couldn't tell them apart. My boss had facial plastic surgery. I couldn't tell. There were movies I couldn't follow the plot in. There were relatives I didn't recognize. I lost my husband in the men's clothing section of the department store. Finally someone explained about head injury and loss of facial recognition.
In right handed people the right occipital lobe allows people to recognize faces and differentiate them from one person to the next. Otherwise it's like looking at faces upside down. You can try that. Faces still look like faces, but the ability to tell one person from the next if the face is upside down is quite limited.
There are some people that are born with the condition, but many people like me acquire it as a result of a traumatic brain injury. There are compensating strategies to use, such as seating charts if you're a teacher, or noticing hair styles or clothing. I tell people I don't recognize people from one setting to the next. If you see me and I'm not responding, feel free to come up and say hello. Please remind me who you are because it's likely I don't recognize you.
If you need help dealing with a traumatic brain injury. Feel free to contact us. 818-223-4116.
|Posted by Margaret Donohue on June 14, 2015 at 9:35 AM||comments (34)|
I did a presentation for a local networking group on neuropsychological testing. Here's a recap:
Neuropsychological testing looks for problems and deficits in functioning localizable to the cortex. Much of the purpose of neuropsychological testing has been replaced by neuroimaging. MRI's or CT Scans. But there are still several purposes for neuropsychological testing.
1. Likely etiology for neurological impairment.
If you think your symptoms are due to a head injury and not a brain tumor, it might be nice to get that confirmed. If you have musical hallucinations, get neuroimagry. Different types of brain tumors show up at different ages. Sometimes following a head injury with concussion, people have more symptoms. Worsening headaches five years post injury is NOT from the head injury. Worsening other symptoms 3 years post injury is NOT from an injury. Head injuries improve with time. Orthopedic injuries can worsen over time. There's some worsening for the first 3 years as the brain adapts to the injury, and headaches of migraine like intensity will continue for up to and including 5 years from injury lessening in intensity and severity as time passes. So if you are past tose time markers and symptoms are worsening, you can get either neuroimaging or neuropsychological testing. Many people don't like neuroimaging, especially people with claustrophobia, because it's a small tube and it's noisy. So to differentiate neurological symptoms neuropsychological testing can be done. Brain injuries generally show a fairly wide specific area of impairment in two places, one smaller than the other. Brain tumors generally show a small specific area of impairment. Neuropsychological testing is used most often to show strengths and impairments folowing a known brain injury or illness.
2. Functional strengths and impairments of a known neurological condition.
Anyone with a recent brain injury would benefit from neuropsychological testing to get a baseline for functioning. If you were in an accident and are pursuing litigation, it's best to ask your attorney for a referral as many personal injury attorneys have specific neuropsychologists they work with for this purpose.
If you have a known neurological condition, neuropsychological testing can document what strengths and weaknesses are present. Neuropsychological testing can also help with strategies for accommodations. It can be used to evaluate capacity for certain types of tasks such as managing funds, living independently, taking medication, etc.
3. As part of a battery of tests, neuropsychological testing can be used to help with differential diagnosis.
This can be true for dementia versus depression, types of dementia, clarifying types of attentional problems. Or other issues. In right handed people right hemisphere neurological impairment can show up as anxiety. In right handed people left hemisphere neurological impairment can show up as depression. (The same is true 80% of the time for left handed and ambidextrous people, but 20% of the time it's the opposite.)
4. It can be used to document the formal need for accommodations under ADA.
ADA testing follows a legal standard established by the California State Bar Association for accommodations for learning disabilities, ADHD, or neurological conditions. These evaluations are lengthy and have substantial documentation of how someone performs with and without desired accommodations. That allows for a functional evaluation of the need for accommodations.
There are a lot of conditions where neuropsychological testing will not be productive and general psychological testing or even just a clinical interview will be sufficient. I can consult on cases over the phone. The consultation is free. If you'd like to be tested, feel free to contct me at 818-389-8384.
|Posted by Margaret Donohue on March 10, 2015 at 7:50 PM||comments (33)|
Head injuries are classified as mild, moderate, or severe based on length of loss of consciousness. There is no concussive injury that should not be taken seriously. So the attorney that asked me in court "Your injury was only mild right?" didn't seem to understand that even a so-called "mild" head injury can produce significant and life-altering symptoms.
The Center for Disease Control uses this definition:
The definition focuses on the actual injury or symptoms, not the possible consequences. For many people, there are challenges in getting an accurate diagnosis and treatment, especially when there is no documented or observed loss of consciousness. There does not need to be a loss of consciousness for a brain injury to occur.
Severity of Brain Injury
Emergency personnel typically determine the severity of a brain injury by using an assessment called the Glasgow Coma Scale (GCS). The terms Mild Brain Injury, Moderate Brain Injury, and Severe Brain Injury are used to describe the level of initial injury in relation to the neurological severity caused to the brain. There may be no correlation between the initial Glasgow Coma Scale score and the initial level of brain injury and a person’s short or long term recovery, or functional abilities. Keep in mind that there is nothing “Mild” about a brain injury—the term “Mild” Brain injury is used to describe a level of neurological injury. Any injury to the brain is a real and serious medical condition. There is additional information about mild brain injury on our mild brain injury page
Glasgow Coma Scale (GCS)
The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person). A GCS score of 13-15 is considered a "mild" injury; a score of 9-12 is considered a moderate injury; and 8 or below is considered a severe brain injury.
Mild Traumatic Brain Injury (GCS of 13-15)
Some symptoms of mild TBI include:
Moderate Brain Injury (GCS of 8-12)
A moderate TBI occurs when there is a loss of consciousness that lasts from a few minutes to a few hours, when confusion lasts from days to weeks, or when physical, cognitive, and/or behavioral impairments last for months or are permanent. Persons with moderate TBI generally can make a good recovery with treatment and successfully learn to compensate for their deficits.
Severe Brain Injury (GCS Below
Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks, or months. Severe brain injury is further categorized into subgroups with separate features:
Following a concussive injury the person remains at risk for seizure for a period of 18 months. To lessen risk of seizure or a second head injury the following are recommended:.
Post Concussive Headaches
These headaches are of migraine intensity, but are not vascular (the hands do not get cold). There is no effective treatment. These occur as a result of sheering injuries and tearing of nerves and nerve fibers. Many people notice improved functioning following these headaches.
Memory Loss and Paranoia
Memory loss produces a sense of helplessness and confusion. Sometimes when people do not realize they have a brain injury, they believe other people are hiding their things, lying to them, or trying to make them feel confused. Labeling items and where they go, having a routine, using a system to track items, and assistance with evaluating thinking like Cognitive Behavioral Therapy, can help people manage memory difficulties.
Depression and Anxiety
In right handed people left hemisphere injuries tend to produce depression, while right hemisphere injuries tend to produce anxiety. Most right handed people with left hemisphere injuries know something is wrong and may complain of forgetting things, being emotional, having difficulty with speaking, writing or understanding people. This sense of something being wrong, knowing it is, and feeling helpless can lead to feelings of depression.
In right handed people right hemisphere injuries tend to produce anxiety. These people may not recognize any changes following the injury but are not able to do things they once were able to do. Since the difficulties are not as easily recognized there is a vague sense of something being wrong, but no clear idea of what it may be. It' only when they attempt to do a task they used to be able to do and can't that they get upset. Mindfullness, meditation, or returning to an easier and well matered task may lessen anxious symptoms.
Long term changes
In severe or moderate head injuries, or multiple mild head injuries there may be changes that occur with blood pressure, blood sugar, and hormonal changes. It's not unusual to find heart attacks or strokes following severe or moderate brain injuries. The development or worsening of diabetes, thyroid or immune problems are also noted. Seizures may be a complication of head injury.
Most brain injuries improve significantly over the first several years. While the person may not get back to who they were and how they functioned prior to their injury or accident, they improve significantly from the initial days after the injury.
Cognitive rehabilitation can be extremely helpful in recovery. Psychological counseling and interacting with other people with head injury can also be helpful.
|Posted by Margaret Donohue on November 2, 2014 at 9:30 AM||comments (32)|
DSM 5 the Psychiatric Diagnostic and Statistical Manual of Mental Disorders is out and updates are available online. The problem is that it's moving away from research based epidemiological discussions about diagnoses and moving more into checklist based diagnoses, based on rating scales and observations of "people who know the individual, or the individual themselves."
So what's the problem?
Here are case examples from just the last couple of weeks (some details are changed to maintain privacy).
|Posted by Margaret Donohue on September 7, 2014 at 11:55 PM||comments (53)|
I've been talking to people about brain injury ever since my second major concussion in 1997. What surprises me is how isolated people feel, the tremendous amount of misinformation they are provided and the number of failed treatments they undergo that may worsen their condition and slow their recovery. So here are the common "weird" symptoms post concussion.
Migraines: Most people with concussion have post-concussive headaches. These are intense searing pain headaches that may or may not be proceeded by an aura, and may or may not result in changes in vision, smell, and sensory sensitivity (light, sound, movement). The major differential is that the person's hands don't get cold. It is not a vascular headache. It is not a migraine. It is a post-concussive headache. It's caused by inflammation and sheering injury to nerve fibers and results in improved brain function following the headache. There aren't a lot of treatments for it. It doesn't respond to migraine medication. These headaches improve over a course of 5 years decreasing in frequency and intensity over time.
Black dots in field of vision: Occasionally mistaken for spiders, roaches, fruit flies, or small moving dots, these are changes to the aqueous humor of the eyes that have concussed. These are usually permanent. People are usually able to adapt in the first 2 to 3 years. Rule of thumb-if it moves only when you move your head it's internal not external. It's not a hallucination.
Balance problems: When you concuss your brain, you often also concuss your inner ear, eyes and may dislocate your jaw. The balance difficulties are due to inner ear problems. Stand and sit slowly. The nausea and vomitting can be treated with over the counter medications, but it may take some time before everything settles back down to normal-usually within 18 months to 2 years.
Paranoia: This phenomena is due to subtle memory difficulties. It's well described in nursing literature with Alzheimer's patients as a response to memory loss, but it's not well described in the neuropsychology literature. It exists and is a commen phenomena.
Personality Change: This is well desscribed in the neuropsychology literature. In right handed people a right sided brain injury often produces anxiety, while a left hemisphere injury often produces depression. This may be the same or opposite side in left handed people. Frontal lobe injuries can result in people much more outgoing and perhaps inappropriate. Other injuries can result in tremendous self-consciousness and excessive shyness. In a few cases the person starts speaking with a foreign accent (Foreign Accent Disorder).
Compulsions: This is better described as stereotypies. These are repetitive behaviors. This is well described in animal literature. There may or may not be an ideational component to the behaviors. This is not an obsession or a compulsion. It's a ritualized behavior that's on a loop and is internally reinforcing. Unlike obsessive compulsive disorder there may not be any underlying thought process other than "i have to do this." Thereare a lot of literature on animals and autistic children with stereotypies. Not so many articles on head injured. But there are some. The syndrome can show up immediately or moths after the injury. It can also occur in an unusual immune reaction following a staph infection in children called PANDAS. These are similar and suggest an immune component to the head injury.
Nerve Pain: Nerve pain shows up in the neuropsychological literature and in the literature on serotonin and norepinephrine neurotransmitters. Nerve pain may or may not be triggered by use of certain types of antidepressants. Often described as tightening, twisting, shocking, or stabbing pain. It may be there are minor focal motor dystonias (twisting of nerves) or it may be a reaction to medication (usually SSRI or SNRI medications), or it may be autoimmune in nature. It can occur immediately or months post concussion.
GI problems: There are numerous reports in the literature often in rehabilitation, nursing and in gastroenterology of the link between concussion and the development of IBS, chronic diarrhea, or constipation. This appears to be a combination of stress, changes in diet and an immune disorder. There is some evidence to suggest it can be treated with antibiotics, probiotics, and an allergen reducing diet until gastromotility returns to normal. The condition may require a permanent change in diet.
Bowel and Bladder problems: There can be difficulty with evacuating the bowel or bladder properly. There may be problems with muscle tone and nerve sensitivity. Accidents may occur.
Meningeal sensitivity: People often complain of increased sensory experience following a concussion. It's too bright, too noisy, too hot, too cold, to spicy in taste, or too odorous. In some cases sensory experience is diminished. If this is only with the sense of smell and taste then it's more likely related to the first cranial nerve that controls smell.
Loss of sense of taste and smell: I was mugged and beaten in 1985. The robber broke my glasses into my face and partially severed my olfactory nerve (CN-I or first cranial nerve). I lost 80% of my ability to smell and more than 50% of my ability to taste. Five years later the nerve started to regenerate and I got pack some of my loss senses. Nerves grow back over different rates over prolongued periods of time. That fact is now in much of the neuroplasticity literature. In 1985 no one thought nerves could improve or regenerate.
Hormonal changes: One of the things that happens with a concussion is that the brain sends a lot of hormones out to try to manage inflammation, bleeding, and the amount of ripped nerves known as sheering. Changes in hormone functions are common. These produce a cascade of effects from weight gain, and sleepiness, or insomnia, loss of appetite, and restlessness. In extreme cases they can contribute to heart attack, stroke, and the onset of diabetes, and thyroid disorders.
Increased frequency of illness: Because the immune system tries to repair the damage caused by the injury and the inflammation following the injury, the immune system is weakened. The brain is using up nutrients to attempt to repair itself. Loss of magnesium, and increases in sugar may contribute to an increased frequency of illnesses like colds and flu symptoms. It may also increase the development of autoimmune disorders.
Sleep Apnea: Hormonal changes, changes in appetite, and weight gain are common post concussion. These can contribute to the development of sleep apnea.
Seizures: Seizures can occur up to 18 months post head injury. Seizure likelihood can be increased by the use of stimulant medication, alcohol, exposure to flashing lights and sleep deprivation. The use of medication for "adult onset ADD" following a concussion may increase the potential for seizures. After 18 months post injury, seizure onset is unlikely.
Sudden death: Apart from situations in which the person experienced a slow and progressive bleed into the subarachnoid space of the brain, following a head injury, there is a small subset of people that may have problems following a degree of gravitational force to the brain for up to 5 years post head injury. This includes motor cycle riding, horseback riding, roller-coaster riding, or any thing that moves a person through space quickly. It may also be the consequence of a second head injury in a short period of time. It may be preceeded by nausea and vomitting and a headache described as a "mule kicking me in the head" or "being struck by a thunderbolt." My advice to people that have had a head injury is not to engage in any of those activities for 5 years post injury.
Fatigue: It's going to take you twice as long to do half as much. You've banged your brain into your skull. It needs time to heal. Sleep helps.
So what can you do following a concussion?
Feel free to do a google search of (Insert name of symptoms here) and brain injury or concussion. These are common and are well documented. Most people with head injury will have one of more of these. There are other symptoms that are less common. The more you can connect with others with head injury the more you can understand how common these are.
We can help you document your injury, symptoms, and can work with your physician, attorney or school to help you recover. Feel free to contact us.
|Posted by Margaret Donohue on August 17, 2014 at 9:55 AM||comments (35)|
Attention Deficit Disorder is a frequently misdiagnosed condition. Psychiatrists seem to think it can be adequately diagnosed by a parent and teacher questionnaire and a mental status examination and history. But then it doesn't adequately respond to medication so they start changing medications rather than reviewing the diagnosis.
It's not how psychologists make an ADD diagnosis.
Parent and Teacher questionnaires are nice information, but do not offer objective data to form a diagnosis. Continuous performance testing using a Test Of Variables of Attention, or a Conner's Continuous Performance Test can provide a great deal of objective data on the type of attention difficulty and can help to differentiate other conditions that may seem similar to attention deficit disorder.
The most common conditions that seem to appear to be Attention Deficit Disorder are inadequate socialization, executive dysfunction, absence seizure, auditory processing disorder, and autistic spectrum disorders. There are patterns of psychological test results that are expected with attention deficit disorder. If those patterns are not present the likelihood that the diagnosis is Attention Deficit Disorder is low.
Continuous performance testing is relatively inexpensive. The equipment for the Connors is portable. If you'd like an evaluation. Contact us.
|Posted by Margaret Donohue on April 24, 2014 at 9:10 PM||comments (36)|
Most people have never heard of a medical or health psychologist. Conceptualized back in the 1960's and 1970's, medical psychologists were initially thought to be physician extenders, very similar to Physician Assistants now. We were taught basic biology and human systems work as well as extensive interviewing skills and history taking. In the 1970's the field of medical psychology split into health psychology and medical psychology. Medical psychology dealt with chronic, serious, terminal illness, complications of medical procedures, and compliance or problems with compliance to medical treatment recommendations. Health psychology focused on wellness, improvement of health, diet and weight loss, sleep hygiene, mindfulness, and stress reduction.
I had grown up working in my adoptive parents' pharmacy so I had a good knowledge of medications coming into the field. My adoptive father, a pharmacist, specialized in compounding medications and had extensive knowledge of botanical treatment of illness (plants used as medicine). So I had information on those as well. I also had the unique experience of having medical conditions that were quite rare and would only be fully diagnosed when I was in my late 40's. In addition to psychological and medical/health psychology treatment, I did post-doctoral training in neuropsychology and forensic psychology (law and psychology).
I started in the field of psychology at the beginning of the HIV/AIDS crisis. I had an office within a general practitioner's office. We shared clients and he billed for my services as adjunctive to his. I was involved in treating conditions that were not improving after several office visits. The majority of these were medical conditions that were difficult to diagnose because the patients and physician were not understanding one another and their descriptions of symptoms. I took vitals such as temperature, pulse, blood pressure, height and weight measurements. I explained lab reports. I reviewed x-ray findings. I treated symptoms of depression and anxiety with psychotherapy. I provided medical research to the physician in charge, and general information to patients.
After a couple of years I opened a group practice with some colleagues and focused on treatment of chronic and undiagnosed medical conditions. That lasted a coiple of years and then I started working as an executive for insurance companies in the new field of managed care. I reviewed medical records for quality and consistency. I wrote policy and procedures for evaluating treatment for both psychological and medical conditions.
In 2009, I opened my own corporation to go back into the field of health and medical psychology. I see people with chronic, serious, terminal and undiagnosed medical conditions. I perform psychological and neuropsychological assessments and evaluations for a host of conditions. The office does legal evaluations for people pursuing personal injury litigations following accidents or injuries, social security disability evaluations and disability accommodation evaluations. We evaluate people looking for evaluations for immigration. We also provide work evaluations or appeal evaluations for people that have been denied employment based on psychological test results.
I have a psychological assistant that primarily works with Spanish speakers. I have another psychological assistant that works with issues related to trauma and women's issues. I have another psychological assistant that works with English or Farsi speaking people doing general psychology. Unlike medicine or nursing, post-doctoral psychological assistants have completed all of their doctoral level education. They are completing between 1500 to 3000 hours needed to sit for the licensing examinations. They work under my supervision.
In addition to my corporation work, I teach graduate school and on occasion undergraduate students in psychology, psychological testing, neuropsychology and neuropsychological testing, ethics, group dynamics, research, statistics, sociology, and psychodiagnostic assessment.
If you're interested in a consultation by me or any of my staff feel free to contact us.