Let me start by saying I’ve been told this assessment is given to HELP you. I just want to make that CLEAR!
I was referred to the Neuro Psychologist because my Neurologist had cognitive concerns due to my severe traumatic brain injury (TBI).
Upon my admission two years ago to UVA, I was rated an 8T on the Glasgow Coma Scale. I looked this up because I had no idea what an 8 meant! 13 or higher suggests a mild brain injury. A score of 9-12 suggests a moderate brain injury. An 8 or less suggests a severe brain injury! I’ve learned something new already!
During her hospital course, Ms. Damico remained in a coma for a few weeks, underwent a bifrontal craniectomy, and had acute respiratory failure that required a tracheostomy. Follow-up neuroimaging during her admission revealed multiple infarcts in the left anterior thalamus, pons, bilateral cerebellar hemispheres, hemorrhagic parenchymal contusions in the bilateral anterior and inferior frontal lobes, and right frontal parasagittal subarachnoid hemorrhage with adjacent cortical edema.
Neurodiagnostics:
Brain MRI (05/02/2022): "1. Right anterior frontal and left superior frontal subdural and subarachnoid hemorrhages. Subdural blood products continue along the falx cerebrum and the left tentorium cerebelli. No evidence of midline shift or herniation. 2. Acute fracture of the left frontal, left parietal and occipital bones with associated scalp hematoma. 3. Decreased volume of the CSF spaces may represent the patient's young age or be evidence of cerebral edema."
Brain MRI (05/07/2022): “1. Acute infarcts in the left anterior thalamus, pons and bilateral cerebellar hemispheres, right greater than left. 2. Interval enlargement of the bilateral lateral and third ventricles. Mild improvement of diffuse sulcal effacement. 3 mm rightward midline shift. Bilateral fluid collections underlying craniectomy site, 11 mm on the left and 10 mm on the right in maximal thickness. 3. Hemorrhagic parenchymal contusions in the bilateral anterior and inferior frontal lobes. 4. Postsurgical changes of bifrontal decompressive craniectomy. Left frontal approach extraventricular drain, unchanged in position. 5. Right frontal parasagittal subarachnoid hemorrhage with adjacent cortical edema, redemonstrated. Small amount of hemorrhage anterior to the right frontal lobe.”
CT Head (09/26/2022): “Postoperative changes of bifrontal cranioplasty with new small volume juxtacortical hemorrhage in the left frontal lobe. "
Video EEG (05/27-30/2022): "1. Generalized reactive slowing of background with possible poorly formed sleep and awake architecture suggests mild-moderate encephalopathy of non-specific etiology. 2. Intermittent focal slowing over the bifrontal regions suggests an area of underlying neuronal dysfunction. The presence of higher amplitude sharply contoured faster frequencies in the same region suggests the presence of a skull defect."
Social History: Ms. Damico grew up in Brown City, Michigan. She typically achieved a 3.9 GPA in school and denied a history of attention problems, learning difficulties, or academic supports. She is a high school graduate and was one semester short of completing her associate's degree to become a mortician prior to her head injury. She was also working as a night auditor at a hotel prior to her TBI and she did not return to work due to physical limitations associated with her injury. She stated she was denied disability, but intends to appeal the decision. She currently lives in Harrisonburg, VA with her husband; her husband's two children occasionally live with them.
Appearance & Behavior: Ms. Damico was appropriately dressed and groomed, was alert, and appeared oriented. She arrived on time and was dropped off by her husband. She was cooperative with the evaluation process overall, and demonstrated appropriate behavior. She presented as euthymic and exhibited pseudobulbar affect, as she often laughed at inappropriate times (e.g., laughing at her difficulties and when discussing losing…)
Now WHAT I lost…you will know the story one day!
Language & Thought Processes: Speech was dysarthric and at times slowed, but was free of paraphasic errors or notable word-finding difficulties. Receptive language abilities appeared intact during conversation. She was able to recall some details of her personal medical and psychosocial history (particularly medical history after her TBI), but had challenges describing history associated with events prior to her TBI (e.g., reason for being prescribed Imitrex, history of depression). Thought processes were logical and goal-directed. There was no evidence of hallucinations or delusions.
Test Observations: Ms. Damico was cooperative with the evaluation and rapport was easily established with the examiner. She remained in high spirits throughout testing. Ms. Damico attended to and comprehended task instructions without difficulty. She appeared to have more difficulty on tasks where she felt more pressure to perform well (e.g., speeded word retrieval).
The areas I'm "average" in right now are:
Intellectual Functioning
Auditory Attention Processing
Vocabulary Knowlege
Auditory/Verbal Memory
Visual/Spatial Memory
Delayed Recall (65%)
Novel Problem Solving with 13 errors
The areas I'm "ABOVE average" in right now are:
Immediate Recall on stories
Immediate Recall on designs
Working Memory
Complex Attention
The areas I'm "below average" or "well below average" in right now are:
Visual/Motor Processing Speed
Speeded Word Retrieval by both letter and category
Now they say that I have a moderate level of depression, and I promise I don't feel depressed! I scored a 26/63 though. They say that I endorse SEVERE self-dislike and moderate symptoms of loss of energy/fatigue (I FADE FAST!), indecisiveness, reduced sleep, and difficulties concentrating. I'm in the NORMAL range of mild anxiety! I have difficulty relaxing and fear of the worst happening. For those who know me personally - the worst thing DID happen. And I'm not talking about the TBI and strokes.
Key Evaluation Findings:
Estimated average baseline intellectual functioning
Performances across cognitive domains were generally consistent with her estimated baseline
Strong performances on tasks of learning and memory and executive functioning
Relative weaknesses/inefficiencies on tasks of processing speed and speeded word retrieval
Self-report measures revealed Ms. Damico endorsed moderate symptoms of depression and minimal symptoms of anxiety
General Clinical Impressions: Overall, Ms. Damico exhibited exceptional performances across the majority of cognitive domains when considering her history of a severe traumatic brain injury. She demonstrated strengths on measures of complex attention, visual learning, and learning and memory of structured verbal information. She demonstrated mild relative weaknesses on measures of processing speed and verbal fluency. She displayed incredible resiliency and positivity that is likely a significant contributing factor to her recovery status and high performances on testing. While Ms. Damico appeared in high spirits and her affect was euthymic, her brain injury appears to have contributed to a presentation that is consistent with pseudobulbar affect, as she frequently exhibited laughter in inappropriate situations and that did not seem entirely within her control, which was most notable when discussing negative factors such as her functional difficulties and losing her... While inappropriate laughter may sometimes be used as a coping mechanism when anxious, the extent and frequency of this behavior during the evaluation indicates that these emotional changes are likely secondary to her brain injury. As such, Ms. Damico may experience greater psychological symptoms than readily apparent, which is consistent with her endorsement of moderate depression on a self-report measure and report of anxiety during the clinical interview.
Ms. Damico's weaknesses in processing speed and verbal fluency, affective changes, and her report of functional challenges in her daily life are consistent with sequela of her traumatic brain injury. While her performances reflect cognitive change from her baseline, these challenges do not rise to the level of a neurocognitive disorder, as she exhibited strong performances across cognitive domains and is functioning independently. It should be noted that testing is completed in a highly structured environment in which she worked one-on-one with reduced distractions, which Ms. Damico appeared to benefit from. Thus, she likely experiences increased cognitive difficulties in her daily life and implementing more structure and supports in her environment will likely be beneficial for optimizing her current cognitive functioning.
ICD-10-CM Diagnoses
Severe traumatic brain injury
Cognitive change
Sleep disturbance
Pseudobulbar affect
Depression
Anxiety
In the end, they gave me a multitude of things I should be doing to help further progression.
Referred for a psychiatric consultation for depression of self-dislike
I am commended for seeking therapy and they recommend that I continue seeking these services.
The Virginia Department of Aging and Rehabilitative Services (DARS) was recommended for vocational therapy to help get me back into working (and also driving!)
Recommend participating in support groups with brain injury. Which I do!! I have Brain Injury Connections of the Shenandoah Valley to thank!
Poor quality of sleep can significantly impact cognitive functioning; especially attention, concentration, and processing speeds).
Schedule "worry" time.
Listen to a relaxing recording to help you fall asleep, reduce anxious thoughts, or block out noises in your environment. (I pray in my head as I lay there anxiously. Pray to help block out the thoughts. Teach me to process them during the day.)
Go to bed and wake up around the same time every day. DONE! 8PM all the way!!
Refrain from watching television or using screens 30 minutes before bedtime
Limit napping time to 20-25 minutes a day. (It takes me that long just to fall asleep!)
Engage in a "winding down" routine each evening.
Avoid caffeine in the afternoon. (DONE! I drink mushroom coffee with NO caffeine!)
If you cannot get to sleep in 20 minutes, get up and do something calming until you feel sleepy again...i.e. stretching, reading, herbal tea drinking.
Establish and maintain an exercise regimen daily.
The app CBT-i Coach can help you with calming regimens and track your sleep.
Mindfulness training has been shown to improve attention/concentration functioning and is also good for your mood, sleep, and pain. We recommend beginning a daily practice starting off with 3-5 minutes and working your way up to 30 minutes.
You may benefit from the use of compensatory strategies to optimize your daily cognitive functioning:
When you finish reading for a period of time, jot down some notes about what you read to help you pick up where you left off.
Focus on one thing at a time and do NOT try to multitask.
Break down larger tasks into small, manageable tasks.
Face towards people and make eye contact when speaking with them - this helps you stay focused. (GUILTY!!)
Work in a quiet place and block out distractions when possible. It may be helpful to use a "white noise" machine, or a fan, to reduce noises.
Do your MOST important tasks during the time of day when you feel most alert/awake.
Repeat important information back to someone to make sure you got it right and to improve later recall.
Continue using alarms, notes, and checklists as needed to keep track of tasks, deadlines, and appointments.
Use "self-talk" to help you concentrate and keep track of the steps in a task. For example, talk yourself (out loud or internally) through the steps involved in a recipe as you complete them. To end this loveliness...I'll leave you with a picture of my "before" self. This may better help understand my "self-dislike."
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