Health and Psychology

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:

• A case of mild traumatic brain injury is an occurrence of injury to the head resulting from blunt trauma or acceleration or deceleration forces with one or more of the following conditions attributable to the head injury during the surveillance period:
• Any period of observed or self-reported transient confusion, disorientation, or impaired consciousness;
• Any period of observed or self-reported dysfunction of memory (amnesia) around the time of injury;
• Observed signs of other neurological or neuropsychological dysfunction, such as—
• Seizures acutely following head injury;
• Among infants and very young children: irritability, lethargy, or vomiting following head injury;
• Symptoms among older children and adults such as headache, dizziness, irritability, fatigue, or poor concentration, when identified soon after injury, can be used to support the diagnosis of mild TBI, but cannot be used to make the diagnosis in the absence of loss of consciousness or altered consciousness. Further research may provide additional guidance in this area.
• Any period of observed or self-reported loss of consciousness lasting 30 minutes or less.

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:

• Headache
• Fatigue
• Sleep disturbance
• Irritability
• Sensitivity to noise or light
• Balance problems
• Decreased concentration and attention span
• Decreased speed of thinking
• Memory problems
• Nausea
• Depression and anxiety
• Emotional mood swings 

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:

• Coma
• Vegetative State
• Persistent Vegetative State
• Minimally Responsive State
• Akinetic Mutism
• Locked-in Syndrome

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:.  

1. No alcohol use for the 18 month period post injury  
2. No activities that increase the risk of a second injury --horseback riding, motor cycle riding, roller coaster riding, sledding, skiing, etc. 
3. Limit use of caffeine.  
4. No return to contact sports until all symptoms of post-concussion have resolved 
5. No activities at height-standing on ladder or chair.

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.  

Improvement

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.