Probing the brain

Tara
Tara Bradbury
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What’s diagnosed as depression or adult ADD might actually be an injury

Dr. Hugh Mirolo, the province’s only neuropsychiatrist, stands next to a large diagram of the human skull. — Photo by Keith Gosse/The Telegram

Part 1 in a six-part series

As a teenager, Randy Preston knew there was something not quite right about how he was feeling. Once an outgoing, fun-loving straight-A student, at the age of 15 he began to withdraw.

“All I wanted to do was go to my room, crawl in bed and stay there,” Preston, now 29, said. “I was tired all the time, I wasn’t happy, and I never wanted to go out.”

Preston figured he was depressed. At one point, he said, he sought help from his family doctor and was put on the antidepressant Paxil — which, instead of lifting his mood, made him feel even worse. He gave it up after two months.

For years, Preston lived with his depression and the problems that came with it: irritability, issues with sleep and aggressiveness, and suicidal thoughts — which he still has occasionally although he has never acted on them.

It wasn’t until last October that he discovered it wasn’t depression he was suffering from at all: it was a brain injury.

A longtime hockey player, Preston had sustained many concussions over the years. Looking back, he realized the most severe one came the same year the depression started: in a moment of excitement over a volleyball game at school, Preston had jumped up and hit his head off a steel frame in a doorway at school, knocking himself unconscious and giving himself a Grade 2 concussion.

These days, Preston is being treated for a brain injury instead of depression, and says the difference in his life, even just in the past few months, is amazing.

“I couldn’t even concentrate enough to read a book before, and now I’m back in university,” said Preston, who’s trying to decide between going into nursing or physical education.

Single specialist

Preston is a new patient of Dr. Hugh Mirolo, the province’s only neuropsychiatrist and the only doctor in the country who practises neuropsychiatry as a specialty. Trained in medicine, neurology and psychiatry, Mirolo deals with the grey area in between these disciplines. He also teaches neuropsychiatry in Memorial University’s faculty of medicine.

The majority of his patients have brain injuries — something many of them don’t even know they have when they first come to see him, he said.

“Brain injury is a silent, hidden pandemia. It’s much bigger than the H1N1 ever will be,” Mirolo said.

In St. John’s, brain injury patients have it particularly difficult because of the northern latitude and frequently overcast weather. Fall and winter are exceptionally hard for them because of the lack of sunlight, which is why Mirolo is emerging from what is his busiest time of year.

One of the most common misdiagnoses of brain injury, Mirolo said — particularly during the fall and winter months — is depression, because both conditions count apathy and sleep disorders among their characteristics.

“Apathy and sleep disorder in brain injury are two things that look like garden-variety depression, but they aren’t and they don’t respond to antidepressants like Prozac, Zoloft or Paxil,” Mirolo explained.

Symptoms of a brain injury aren’t straightforward, but can also include problems with memory, concentration and organization, narcolepsy, visual and auditory hallucinations, aggressiveness, insomnia, a low alcohol tolerance and even difficulty with fluorescent lights. Many of these, on their own, are normal, Mirolo said, but may indicate a brain injury in certain combinations.

Many people with brain injuries, like Preston, seem typical and are high-functioning, with no obvious symptoms, Mirolo said.

“Brain injury is freaky, because it’s camouflaged in the rest of the population, and if you’re not in this business, it’s difficult to find it, particularly with the connotation it has. Usually my patients come in after bouncing back and forth from psychiatry to neurology to family practice, not necessarily in that order, and we have a four-year waiting list, so you can get a pretty good idea of what I’m talking about when I say it’s a pandemia. I’m not exaggerating.”

Brain injuries can also look like other conditions, Mirolo explained. He has a number of patients who were previously diagnosed with seasonal affective disorder, Alzheimer’s disease or dementia, schizophrenia, personality disorders, autism and attention deficit disorder (ADD). Mirolo said he’s never seen a patient with a true diagnosis of adult ADD.

“In kids, yes, that diagnosis is present without brain injury, but a number of those kids that I’ve seen as adults, a number of times had multiple brain injuries during early life,” he said.

“They got the diagnosis of ADD when in reality they were getting multiple or one or two brain injuries, of one cause or another.”

A brain injury is not the same as a head injury, Mirolo explained, and doesn’t require a blow to the head. Brain injuries can be caused by chemicals like carbon monoxide, infections like encephalitis and meningitis, or a near-drowning, for instance.

Whiplash or a jolt to the body without hitting the head can also cause the brain to be injured as it knocks around inside the skull.

How can a person live with a brain injury and not know it? Because we are our brains, and we rarely question ourselves, Mirolo said.

“I usually tell my patients it’s like bad breath — you are the last to know you have it.”

Tough to diagnose

General health practitioners can easily miss a brain injury because it can be well-camouflaged, and because it’s not often visible on scans in mild to moderate cases.

“You can photograph the brain until hell freezes over, and a number of times, there’s absolutely nothing,” Mirolo said.

“It’s like if you pull on a computer wire, the little copper things inside might break, but the wire itself will look perfectly OK. The computer will not function, however.”

Family doctors generally don’t have the time to do a thorough assessment for brain injury, simply because of the nature of their busy practices, Mirolo added. His patient assessments can take weeks and include interviews with family members and questions about the patient’s life right from birth or even in the womb.

He often receives referrals for patients who — he later discovers — suffered a head trauma in a semi-serious car accident, for example, and were deemed fine after spending a night or two in hospital with no obvious problems. The person might have started experiencing insomnia and unusual irritability or depression within days, weeks, months or even years later. The symptoms were never connected to the head trauma.

How quickly symptoms appear depends on the magnitude and location of the injury, and what baggage the person carried into it, whether it be migraines or depression or something else.

“Typically, whatever luggage you had before the injury will be magnified,” Mirolo explained.

Treatment for a brain injury can involve medication and vitamins, phototherapy treatment with a specialized lamp that replicates sunlight, proper sleep hygiene measures, and a cognitive rehabilitation in the form of activities that stimulate the brain and use the hands at the same time. Mirolo prescribes chess as a mandatory activity for most of his patients, since it happens to hit the wounded brain where it is weak, he said, and he gives them the option of taking up activities like painting and drawing, cooking, embroidery or music.

“It’s like weightlifting for the brain,” Mirolo said. “The brain is like a muscle: if you don’t exercise it, you lose it. If you have a wounded muscle, you will lose it a lot faster.”

As part of his treatment, Preston plays chess, does embroidery occasionally, and paints.

He said he’s relieved to be receiving treatment as a brain injured patient, and is looking forward to feeling even better.

“It’s changed my life dramatically. I’m totally, 100 per cent happy with this diagnosis. It put my mind at ease.”

tbradbury@thetelegram.com

www.twitter.com/tara_bradbury

In Monday's Telegram: The link between the old hag and brain injury

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  • Melissa Wild
    April 29, 2011 - 18:23

    I am the manager for a brain injury awareness and fundraising event called A Run To Remember where David McGuire has set out to run a marathon a day across Canada to create a movement and change the face of brain injury in our country. We started this journey in St. John's, NL on March 31, 2011 and are now approaching Port-aux-Basques. Since departing St. John's we have had the opportunity to speak with so many people who have been touched by brain injury, either themselves or those close to them. Each time we hear another story it reaffirms to us why we are going across Canada to raise awareness and funds for this worthy cause...brain injury is everywhere and the effects are felt not only by the person but all of those around them. Of all types of injury - brain injury is the most likely to result in permanent disability and death. Acquired brain injury has become recognized throughout the world as a problem of epidemic proportions. Unfortunately, due to the cognitive nature of the disability it has become known as the Silent Epidemic. Brain injury results in a complex variety of physical, cognitive and behavioural problems. Unless significant physical injuries occur it is often misdiagnosed or missed completely. Cognitive difficulties are not always obvious, but have devastating consequences. Brain injury is an issue of enormous proportions with devastating social and economic consequences. In the majority, this is a condition of the young. The highest incidence group are just starting careers and / or families and do not possess significant resources to fall back on when injured. The cost in health care, lost wages, increased reliance on social welfare, justice costs and the devastating impact on families are nearly incalculable. If we prevent just one serious brain injury each year, over the lifetime of the first injury prevented, we realize a support care cost savings of over $90 million dollars. Prevention of brain injury is one of the most cost effective strategies to save health, social service and criminal justice resources. The goal of A Run To Remember is to bring brain injury to the public stage and create a movement in Canada. No longer a silent epidemic - we aim to: increase funding/services for those living with injury, increase public awareness and promote injury prevention for all. Please spread the word and support David McGuire in his journey across Canada and become a part of the movement. Visit the website www.runtoremember.com or join us on our social networking sites: facebook.com/r2rcanada twitter.com/r2rcanada youtube.com/r2rcanada flickr.com/r2rcanada Inspire Change... Melissa Wild Run Manager, A Run To Remember runwild@braintrustcanada.com 778-821-0395 www.runtoremember.com

  • CC
    April 10, 2011 - 16:32

    Good job, very intriguing article. All the best to Randy as well.

    • Judith Day
      April 13, 2011 - 20:44

      I hope Dr. Mirolo publishes an article on the brain damage that can result from taking mind altering drugs. perhaps coming from him now the users will think twice about taking them when they learn how studies show that some of these drugs actually shrink the volume of the brain and cause permanent short term memory loss. neurotoxicity from psychotrophic is damaging many young brains and people must become more educated about it before permanent brain injury results. It is too late when parkinsons, muscle stiffness, muscle weakness, and deformities are the result.

  • D
    April 10, 2011 - 07:52

    thank you, thank you thank you, a million thank yous for publishing this article. finally there is proof of what i have known and said all along. i too was put on drugs for depression, zyprexa, celexa and benzetropine. they didn't do any good, only made things worse and caused ireverseable physical damage. i worked on my own to bring myself back and i never once had succidal thoughts either before or after. i only wish i had known about this doctor, i know exactly what happened to me and now i also know why. i always knew about brain injuries and that they could cause problems much later, and it doesn't help when you try to tell someone and they look you straight in the face and tell you that didn't happen. i am no medical doctor but i started walking a lot some times as much as 10 kilometers a day, changed my diet and my additude. while i am not where i would like to be. i am almost there.

  • c
    April 09, 2011 - 15:10

    I wrote a comment long before Dave B posted his but as usual when writening into the Telegram, what does get posted is VERY selective even though I had a positive comment about the aarticle.

  • Dave B
    April 09, 2011 - 10:56

    Fantastic article! I look forward to the next installment.

  • c
    April 09, 2011 - 10:46

    Oh my I can't believe what I'm reading!!! I had a concussion a couple of years ago and my head hasn't been the same since.I was brought into emergency by ambulance and after waiting to see a doctor was told to go home and rest...without a scan. I was sick for almost a year with dizziness and nausea. In the tiem since I did have two scans done but nothing showed up. I get vicious migraines now, worse than before the concussion, just coming off of one now. I was very sick yesterday and last night I had to keep the curtains closed and wear an eyemask most of the day until the sun went down. Sometimes the day after I have tremors. I was thinking last night on going to my family doctor to have another scan done to see if there was anything that may have been missed. I get a migraine at least once a week or week and a half. I will certainly be looking forward to the other five parts to this series.

  • Steve Morrisey
    April 09, 2011 - 08:08

    I can't wait to read the next part, this article addresses questions i have been asking for a long time, thanks Steve - Looking forward to more!