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