Welcome to the TBI-HELP Live Chat

Today's topic is: "Executive Functions and Traumatic Brain Injury."

Our Guest is: Dr. Jennifer McCaine, Psychologist, Jamaica Hospital Medical Center, TBI Unit

[19:12:45] Mod: Welcome to everyone and I thank you for being so patient for the delay. We are ready to go!
[19:13:22] Mod: Welcome to Dr. Jennifer McCain. Dr. McCain's topic of discussion this evening is "Executive Functions and Traumatic Brain Injury".
[19:14:14] jennifermccain: Good evening everyone. I apologize for the delay.
[19:14:33] jennifermccain: I'm very excited to be with you all tonight.
[19:15:04] Mod: Dr.McCain, What is the meaning of "Executive Functions?"
[19:15:54] jennifermccain: Executive functions can be quite a difficult concept to understand. I usually find that the easiest way to explain this concept is to begin with an analogy which I learned a while ago, and which helps to make the idea of 'executive functioning' not so esoteric. You can think of your brain as an integrated organ, yet one in which has individual jobs. Compare the brain to an orchestra. AN orchestra is comprised of many different types of instruments, such as violins, flutes, clarinets, trumpets, and so on. This is kind of like your brain. Though this is an oversimplification, there are parts of the brain which are responsible for different skills, such as language, memory, etc. Just like an orchestra, these parts of your brain can function on their own in certain circumstances. However, in order for all of these skills to work together in an organized fashion, it needs the help of executive functions, which can be compared to the conductor of the orchestra. Thus, without a conductor, the instruments may be able to play music, but the result is usually a disorganized mess. This too can happen with executive dysfunction. YOur speech, memory, and so on may be able to function in certain situations, but the resulting behavior will likely be quite disorganized and not necessarily goal-directed. 
    For a more formal definition, you can think of executive functioning as the direction and organization of all behavior (emotional as well as cognitive) in order to attain goals and regulate behavior that is consistent with attaining such goals From a practical, everyday perspective, executive functions include setting realistic goals based on accurate self appraisal, monitoring your behavior and evaluating your performance in relation to these goals, problem solving and changing behavior to come about obtaining the best solutions.
[19:26:57] Mod: Why are executive functions so vulnerable to damage by TBI?
[19:27:58] jennifermccain: In the typical head injury, the skull abruptly hits a relatively stationary surface (e.g., a windshield in the case of a car accident or pavement in the case of a fall) The skull makes an abrupt stop, and the brain which is inside has really no place to go--as it is encased in the skull pretty tightly and cushioned by the meninges. What happens is that the brain may be stretched and rotated within the skull. Two main things happen. One is that the individual axons (part of the neurons) become rotated and torn This can cause diffuse damage to the brain (I won't get too technical, because it can be quite tedious) When this happens, it is called diffuse axonal injury. The second thing that happens are focal cortical contusions. These are local abrasions on the brain's surface resulting directly from the impact of the brain against the interior of the skull. The linear forces of the injury may cause abrasions as the point of contact and directly across the skull from the point of contact. This is referred to as coup-contrecoup injury. If the impact is sufficiently intense, it can accelerate the brain into a rotational movement, and contusions may also occur in the frontal part of the brain. This is important, because executive functions are assumed to be housed int he frontal lobes. The frontal lobes are particularly vulnerable to damage after TBI, because they sit on bony projections, and thus become more damaged.
[19:38:10] Mod: Where in the brain are executive functions located?
[19:38:55] jennifermccain: As I mentioned, the frontal lobes are usually associated with executive functions.
[19:39:39] Mod: How does damage to the executive functions affect other cognitive skills?
[19:40:27] jennifermccain: Damage to the frontal lobes is often associated with good recovery of motor, sensory, and linguistic functions. This is especially true and is seen on neuropsychological testing. Thus, the person with frontal lobe or executive functioning damage may look good on testing, or in the context of a highly structured and routine environment. Conversely, executive dysfunction can cause many problems. For instance, despite good recovery in the previously mentioned areas, debilitating problems can be seen with the regulation of cognitive, behaviors, social and communicative functioning. It can result in difficulty with regard to attending, planning, organizing, learning, problem-solving, and reasoning in unstructured real life tasks even though they may show good performance on highly structured neuropsychological tests. This brings me back to the orchestra-- the musicians may be able to play an over learned song (God Bless America) witout their conductor, because it is so automatic and over learned. However, introduce a new song which they have never seen before, and the result will be a disorganized cacophony. Same thing with cognitive and emotional functioning---they may be fine in highly predictive settings, but once novelty is introduced, they will have considerable difficulty. Other areas where you may see executive dysfunction wreak havoc are: communication (rambling or impoverished discourse, reduced comprehension of lengthy material, inefficient retrieval of words, difficulty comprehending verbal abstractions) You also may see inappropriate social-communicative behavior, especially in stressful social contexts.
[19:49:50] Mod: Rail: How much of personality is related to executive functioning?
[19:51:07] jennifermccain: Personality changes are one of the biggest difficulties that can be brought on by head injury. Often, it is the family members and friends who have the difficulties and complain, as the person who was injured is often unaware of his personality changes. In particular, complaints/concerns usually surround issues related to apathy, concern, sexual/socially inappropriate behavior, impulsivity, lability, and irritability.
[19:52:48] Mod: James: My good friend had a motorcycle spill that did significant damage. He was doing really well and we were optimistic. He had a series of seizures that scared us all and was given medications that stopped the seizures, but his personality changed with that medication. It this an executive function issue, and what should we know about our friend?
[19:53:19] jennifermccain: James, this is a difficult question to answer, as both seizure medications and TBI can effect personality. However, some common changes that may accompany seizure meds include: slowed thinking, memory lapses, apathy/lack of concern, decreased concentration, and sometimes agitation. It depends on the seizure medication, what types of seizures he was having. This is important because a seizure is a symptom, and not a disease. By this, I mean that a seizure signifies that something is wrong in the brain, and is causing the seizure. Thus, it could be the meds., the TBI, OR and problem causing the activity that could be individually responsible for the personality changes. Most likely, it is a combination of all of these. It also depends on the site of his injury and type of injury from his accident.
[19:56:58] Mod: James: Will his personality return if the seizure medications are able to be discontinued or has further damage resulted 6 weeks after the crash?
[19:57:29] jennifermccain: This is a complicated issue. Further damage is highly unlikely, unless he has something else going on besides his initial injury (e.g., hydrocephalus, increased intracranial pressure)---and if personality changes are the only difference, this is not that unlikely. However, it sounds as though your friend should really follow up both with his DR. (neurologist?) What kind of personality changes?
[20:01:55] Mod: Wildmanmax: Yes dr. when do you stop recovering?
[20:02:04] jennifermccain: This is a very broad question, and one that many individuals who have been injured and families ask a lot. It really depends on the specific kind of injury (TBI, stroke, tumor, degenerative disorder), and preexisting factors, like age, gender, social supports, personality, and so on. If your friend just returned home, he may also begun to experience depressive feelings.
[20:04:39] Mod: Syd [James cohort, about the same case]: He seems to loose interest in his work, we were so positive when he wanted to get back into the video technology right away - even with a broken leg - and now he is really "down" and doesn't care, your description is exactly right?
[20:04:45] jennifermccain: This often happens when people leave the hospital--real life finally really sinks in, and it is overwhelming to say the least. These adjustment issues may be interacting with the other things I mentioned. It is impossible to disentangle the different intermediary variables.
[20:05:32] Mod: Wildmanmax: I'm 7 year's post myself gave up on further recovery.
[20:06:11] jennifermccain: I hate to hear that you've given up, though most rapid recovery does occur within the first few months to a year.
[20:07:31] Mod: Well I see that our time is up for this evening. I want to thank Dr. McCain for an interesting and informative chat session. I invite her back in the future for another session. To all of you, thank you for your participation and I look forward to seeing you next week. Have a wonderful week and be safe! Good Night.
[20:08:26] Mod: WVanGorp: Dr. McCain did an excellent job this evening. Thank you.
[20:08:57] jennifermccain: Good night everyone. It was a pleasure to sit down and chat with you this evening. Take care and be well!