More than two percent of the United States population is reported to have sustained a Traumatic Brain Injury (TBI); within one year of injury, approximately 25-50% of the survivors experience a certain degree of depression (Gualtri & Cox, 1993). When a person is depressed, he or she is imprisoned in a morose mood, and it feels as if there is no escape. However, there are strategies for alleviating the suffering that results from the imprisoning grasp of post-traumatic brain injury depression.
Post-traumatic brain injury disturbances tend to bring about uneasiness, apprehension, extreme sadness, dejection, and hopelessness in survivors. Some are affected for a short period, and others over a longer term (i.e. transient and prolonged). Transient depression lasts up to three months, it presents itself as a depressive syndrome without anxiety. Prolonged depression lasts for more than six months and is accompanied by an anxiety disorder (Jorge, et al., 1993; Jorge, Starkstein, Robinson, & Arndt, 1994).
Influences
Since post-TBI depression often seems to occur immediately following neurological injury and is accompanied by psychosocial impairments, researchers believe that TBI and depression are correlated (Jorge et al., 1994). As mentioned in a study by Lehr, "so-called organic symptoms of TBI" are those that are directly linked to damaged cerebral tissue, thereby resulting in altered behavior. These direct effects of brain injury often include behavioral and social-emotional changes, such as an increase inappropriateness, aggressiveness, or frequent mood changes" (as cited in Savage and Wolcott, 1994, p. 240). Some of the psychosocial impairments may include deficits in self-awareness, self-regulation, self-esteem, fluency of expression of thoughts and feelings, the ability to interpret emotions and the subtle non-verbal cues of others, and the ability to initiate activities or function in relationships (Armstrong, 1991). Any of these psychosocial impairments can lead to depression. It is common for depression to emerge as a result of such uncontrollable and sudden changes in one's life. For example, post-injury patients often find themselves unable to express their thoughts and feelings clearly. They isolate themselves by being uncommunicative and this can lead to loneliness, frustration, and ultimately depression.
Emotional difficulties are often interrelated with neurological and/or cognitive deficits. Cerebral dysfunction affects a person's reasoning, judgment, personal relationships and outlook (Armstrong, 1991). Jimmy, an adolescent who has sustained a closed head injury, has a rash of symptoms; he can be used as an example. He has difficulty reading other people's emotions and often misunderstands the underlying meaning of what is said to him. He already tends to detach himself from others and deficits such as this cause him to be further distanced from friends and family. Jimmy's family should respect his need to spend time by himself, yet they should be aware that one of the most devastating and depressing effects of a TBI is social isolation (Armstrong, 1991). For more information on unmasking concealed chronic illness and pain, see http://www.writefaceforward.com. Author Carol Sveilich, is working on a second book on the topic of depression and mood disorders.
Emotional trauma is hard to read. So many influences transition a survivor, we cannot assume that one symptom leads to another. Simply the trauma itself or just neurological interference may lead to a depressive state; there are additionally the resulting complications.
Many Faces of Depression
Depression has many influences or causes and is manifested in many forms of behavior. Being depressed is not always easy to detect - it is a camouflaged illness that is manifest by symptoms of varying severity.
In a study conducted by Jorge and associates, symptoms were grouped in two categories, psychological, and vegetative. The less severe category of depressive symptoms, the psychological, consists of worrying, brooding, loss of interest, hopelessness, suicidal plans, social withdrawal, self-depreciation, lack of self confidence, simple ideas of reference, guilty ideas of reference, pathological guilt, and irritability. The more severe symptoms of depression, the vegetative, include autonomic anxiety, anxious foreboding, morning depression, weight loss or gain, delayed sleep, subjective anergia, early morning awakening, and loss of libido (1993). In a study by Prigatano (1991), it was mentioned that certain TBI patients might deny the presence of a depressed mood as a part of a general unawareness deficit or a denial syndrome. A brain injury results in psychological and social difficulties. Symptoms such as these can be a result or cause of a depressive condition.
Modifying Depression
Apart from medical interventions (i.e. anti-depressants, mood stabilizers, etc.), a depressive state can be modified through physical, emotional, or psychosocial interventions. An example of a physical approach to intervene into a depressive state of mind is the use of pharmaceutical methods. Emotional relief is obtainable through participation in activities such as the expressive arts; psychosocial rehabilitation can occur by attending brain injury support groups. For brain injury survivors, some or all of these methods can be used, and the support, encouragement, and involvement of peers and family is crucial. For more information regarding personal rehabilitation, see http://www.graymatters4u.com - Rehab Services.
Emotional Rehabilitation
The expressive arts can be used in rehabilitation to help the individual with TBI come to release pent up energies and to better understand him or herself. The arts can help reduce a person's general level of stress and can help him or her creatively compensate for deficits. Painting and dance are two methods of artistic expression, which can help promote self-understanding, emotional self- expression, and the reduction of stress (i.e. many other artistic modalities may be used to help a student learn to cope with trauma and personal changes).
Poetry
Writing poetry is a literary tool that facilitates recognition, expression and acceptance for a survivor. It is a unique intervention for brain injury rehabilitation because it facilitates psychological, emotional and cognitive development. The author of this article has written a book of poetry about brain injury titled Gray Matters (see description at the end of the article). This poem on depression, "Melt Down", is taken from a chapter about the symptoms of brain injury.
Melt Down
Depression...
Deflates me,
Frustrates me,
Invalidates me,
I fluctuate,
Wander into self-hate,
Tend to isolate,
Myself,
I usually underrate,
I need someone to...
Medicate,
Vindicate,
Tolerate,
I am real,
and I feel,
But don't see the beauty
that is within me.
I am an infidel to myself.
I'm smoked,
I can't see through my fog,
I'm being charbroiled,
Churned,
Melted down.
It's like...
I tore my flesh out of my ribcage,
I'm scarred,
Hurting,
I wallow inside,
Watching my heart pulse and quiver -
Want to reach in,
Pull out my fear,
Only I clutch hold of the meds,
I confess,
I am a bit afraid
of where my depression has led.
It wraps into the subconscious
like a snake,
Even my strongholds
I let it take.
I avoid everything that makes me feel good,
Then there's no chance
of feeling like I could.
I'm simmering,
I walk my path alone.
I've yet to find someone
that harmonizes with my tone.
I want to tell you -
Self-esteem can be hard to inflate
all on your own.
I tell myself -
My attitude is my ammunition.
Good or bad,
It's my decision.
I swing from that moody tree,
But I'm losing grasp of the vine.
Personal importance stabilizes,
But mine is waning.
My strength of self is draining.
I'm liquifying,
Simmering, frying,
I ruminate about dying,
I'm melting down.
Painting.
Expression through painting, allows emotions and attitudes to be expressed either directly or symbolically. The intensity of feeling can be expressed through exaggeration or focus on particular parts within a painting. Such distortions such as the flexible use of color and the exaggeration of form can also develop the emotional impact of the painting (Lowenfield, Brittain, 1987), and should be encouraged. The painting also serves as a reminder feelings, thus the act of painting can serve in familiarizing a person with his or her current or past emotions and allows for the touching over, redefining or healing of harsh memories.
Dance.
Dance is a means of emotional and imaginative expression. It helps the individual learn how s/he moves, how her/his body language is perceived by others and to create her/his own form of self-expression. Expressive movement can also serve as an act of claiming independence (Talbott, M., 1996).
Dance can help to alleviate the impact of life's stresses and also exercises certain processes of the brain that may have been disturbed in a brain injury. Dancing applies the functions of the cerebellum, basal ganglia, and the pons, which control balance, coordination, movement, and the alignment of thought and movement.
Creative compensation is a self-inspired process of adapting. A survivor can utilize this inspiration in adjusting to psychosocial or other type of problems in new and innovative ways. In dance class, Susie, a TBI survivor, noticed that certain movements she made caused people to smile, even to laugh. Susie is a woman who is usually very self-conscious when people notice her impairments. The next time her slowness and forgetfulness attracted a group of people's attention, Susie tapped her hand up in the air, as if to music, and spun around. The faces of five curious onlookers turned to laughter. This relieved Susie of the stress of everyone's attention and was her means of creatively compensating.
Psychosocial Rehabilitation
Support groups are strongly recommended for the survivors and their families. Support groups can provide survivors and their families with a setting in which each member can be understood and supported; additionally, families can find information they need at the meetings. For the person who has sustained an injury, the support group supplies peer relations, feedback, modeling and an environment for strategizing about methods of compensating. It enables the individual to utilize the modeling of others with the same concerns, to feel less isolated, to demonstrate competencies, and to help others, thereby increasing his or her own self esteem. The meetings can also help a person improve communication and social skills, and become more aware of injury related deficits and residual assets (Armstrong, 1991).
An individual with post-traumatic depression can be greatly affected by the attitudes of friends, family, therapists, teachers, and associates. Some standpoints serve to discourage a survivor's rehabilitation (e.g. a protective attitude may shun a person's participating in activities that may be necessary for the individual in order to learn to better get by). It is important not to address a depressed person with a sentiment of wanting to cure him from his or her life's woes; better approach a survivor with an empowering, "you are more than your injury" approach. A survivor can always use encouragement and guidance from friends, family or therapists; nevertheless, recovering individuals can learn to apply strategies that can help to free them from the imprisoning grasp of depression.
A brain injury survivor wrote this article whilst pursuing her Masters degree in Special Education specifically for brain injury survivors. She investigated on the Internet the relationship between head trauma and depression and found only a remnant of research, yet she personally knew there was a direct relationship. She sees it as "neurological traffic" and thinks that bundled up nerves can be redirected and depressive congestion can be alleviated, with a conscious effort in place of or to supplement pharmaceutical interventions. Research in the field is still under development, there is a definite need to know the "inside perspective" of brain injury.
Gray Matters
Ms. Lerner has published a book of poetry about brain injury titled Gray Matters, Brain Injury: The Inside Perspective. Her book's aim is to give readers a feel for what it is like to walk in the shoes of a brain injury survivor. In the book, she gives her experiential insight, as well as a professional understanding of what brain injury entails. Many books about brain injury are clinical and unapproachable by the lay public; Gray Matters serve as an entertaining and understandable resource of knowledge about brain injury. The website, http://www.graymatters4u.com is a wonderful resource to learn more about brain injury and the book can be purchased on the site.
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