Fear and terror clearly have their own psychological effects, but so does physical damage to the brain. Schizophrenia, once considered a disease of the mind, is now known to be the result of abnormalities of the chemicals and neuro-transmitters that keep the brain functioning and organized. It is no longer a mental illness where strange voices speak to troubled people, but a medical disease resulting from physically defective transmitters with the ensuing neuronal dysfunctions. No voices, only malformed or misdirected chemicals, a disease of the brain, rather than of the mind.
In this brave new world of high-tech scientific medicine, sorting out the brain from the mind has become, as has all of modern medicine, a matter of accurate weights and even more accurate measurements. The basis of all science may be intuition but the nuts and bolts that hold the sciences together and give science it’s credibility are the data points and probability constants. The axiom of science is that “if you can’t weigh it or measure it you don’t know it.” Or put more dramatically, “Forget about the Whys, find out the How.” That is certainly now true of psychiatry and psychology, as it is of all of medicine.
The obvious craziness of George the Third, with his blackcolored urine, was discovered, in the retrospective microscope of Twenty-first Century medical science, to be the genetically inherited disease porphyria. It is a disease of so-called intermediate metabolism that can damage brain cells by the body’s production of abnormal proteins, leading to bizarre and irrational behaviors.
This same sorting out of the body from the mind that happened with schizophrenia happened again in 2010 with the publication in the journal Science describing the discovery of a new retrovirus contaminating the nation’s blood supply. The virus called XMRV was found in 10 percent of the stored blood. The importance of this finding is that this virus is the same virus that has recently been discovered in over two-thirds of patients with a diagnosis of Chronic Fatigue Syndrome.
Physicians have felt for decades that Chronic Fatigue Syndrome is a psychological and not a medical disorder. Despite considerable effort, no causative agent has ever been found, nor any abnormal bodily function or lab test, to point to a physical cause for the condition. CFS is considered to be a debilitating psychological condition restricted almost entirely to unhappy, upper-middle-class Caucasian women living in the suburbs.
Not only has the XMRV virus been found in a majority of these patients, and not in matched controls without the condition, but there is now a growing concern that contaminated XMRV blood, injected into surgical patients who have experienced significant blood loss, may be the real cause of the ongoing fatigue, exhaustion, and depression that occurs after surgery. It has always been explained away as the stress of the surgical procedure combined with the physical exhaustion of post-operative blood loss.
The scientific article that documented the presence of this virus in patients with Chronic Fatigue Syndrome was titled, “A New Virus for an Old Disease.” But scientists did have to find the virus before anyone could connect it to the physical cause of the symptoms. It would appear that the overwhelming exhaustion in these patients, long dismissed as their problem and due to the uncontrollable stresses of surgery, may be due to an infection with this newly discovered retrovirus somehow affecting both the body and the brain. A condition that physicians thought, and were able to convince family members, was no more than an indulgent psychological problem turned out to be a real disease caused by a real virus affecting real parts of the body.
Richard Feynman, the famous physicist, would start his graduate level classes on quantum mechanics at Cal Tech by reminding the students that whatever they might think of science, its real value was “that it keeps us from fooling ourselves.” What is true of physics is true in medicine. The difficulty in sorting out brain damage from a psychological condition lies in the very complexity of the brain and the need to have very precise tools in order to measure, and document, what is normal, what is not, what has remained healthy, and what is damaged or diseased. And all that starts with the anatomy.
And that is precisely where the issue of TBI and PTSD physically come together.
From the time of the earliest dissections, the brain has been divided on simple observational grounds into gray and white matter, and that is precisely how the brain actually looks. The gray matter is gray because it is made up of layers and layers of densely packed neurons, or brain cells, piled in the hundreds of thousands, one on top of the other, throughout the outer sections of the brain. The white matter, that does indeed look white at surgery or at autopsy, is made up of the axons, long slender microscopic fibers colored white because each individual axon is insulated from all the surrounding axons by a thin outer sheath of a white fatty insulating substance called myelin. It is these covered axons that not only connect the billions of individual neurons within the brain, but eventually come together in ever larger fibrous bundles to form the spinal cord and finally, the large peripheral nerves that carry nervous impulses to the muscles as well as all the different organs of the body. Some of these fibers are only microns in length, while others reaching from the brain to the heart, lungs, kidneys, and the muscles of the arms and legs may be yards long. Electrical signals move up and down these fibers to keep the whole system working together.
The white matter with its billions of axons makes up the wiring of the central nervous system. Some of the largest bundles of these fibers are the axons that connect the neurons of the right side of the brain with the neurons of the left. The largest of these, the Corpus Callosum, lying in the very center of the brain between the brain’s two major hemispheres, contains over 200 million fibers. The average internet cable running into your house contains less then 50,000 fibers.
Taken together, the brain is an amazing electrical grid that makes the whole body work, from how we move, to how we see, to why and how our hearts speed up and slow down, to how we continue to breathe in a regular fashion even when we sleep, and why we can think and how we remember. It is no wonder that damage to these fibers leads to all of the problems and symptoms of Multiple Sclerosis. Indeed MS, and other neurological disorders, are classified by neurologists as specific diseases of the brain’s white matter that, for some reason, lose their outer protective myelin coating and because of the physical damage to the fibers, can no longer function as designed.
The gray and white matter that make up the major components of the brain, along with the supporting blood vessels and connective tissues, are organized into layers of different densities depending on how many cells, and how many fibers, are packed together into that one specific area of the brain. When examined in a living patient, these different layers of brain tissue have the consistency of differing layers of Jello. It is these different layers of densities that make the brain so exquisitely sensitive to motion, whether from a blow to the head or a passing blast wave from a roadside bomb or suicide bomber.
These different layers of the brain tissues, with their different masses like those different layers of Jello, move at different speeds when set into motion. It is the different speed at which these layers move that generates the internal shearing forces between layers that tear the bridging microscopic veins and arteries, connective tissues, and bridging nerve cells. A brain set in motion is like a layer cake suddenly placed on the top of a jackhammer. And that is happening all the time now in Iraq and in ever increasing numbers in Afghanistan. As the neurosurgeons have pointed out, the damage from that shaking can be more widespread and more neurologically disabling to the person than a brain hit by a bullet.
Shaken Baby Syndrome is the most dramatic example of the damage that can be caused by simply setting a brain into motion. It is well known within pediatrics as a major life-threatening injury of child abuse, leading to significant central nervous system injury including blindness, retardation, and even death. The damage results from the brain moving back and forth within the skull, leading to significant bleeding and damage to the connections between the brain’s different
layers.
An infant’s neck muscles are not strong enough to hold the head steady when the child is being shaken, allowing the head to snap back and forth in rapid succession. The physical forces of the head moving and the brain remaining still are exactly the same as the physical forces that work on a brain moving while the skull remains motionless. In either case, the results are the same. The soft tissues of the frontal and basal lobes of the brain smash up against the rigid inside of the skull, causing significant bruising to the surfaces of the brain, while the inner parts of the brain, moving at different speeds and different distances, tear apart the internal connections.
The dynamics of a shaken baby are basically the same as an adult brain exposed to a helmet-to-helmet shock, hitting the back of your head on the ground while chasing a fly ball, or being exposed to a shock wave from an exploding IED. It is accepted that any or all can lead to physical injury and long-term brain damage, with significant and often cognitive impairment.
There is no trouble in diagnosing the big internal bleeds, the expanding blood clots, or the severe brain swellings, any more than it is difficult to make the diagnosis of a brain tumor or of meningitis. The problem is that the more subtle the injury, the baby that simply hits its head falling to the floor from a chair or the marine standing some distance from an exploding IED, the more difficult to make the diagnosis of a brain injury. You do need some measurement of what is normal and what is not before you can give a diagnosis of injury or damage, that’s just how medical diagnosis works.
An adequate determination of mild brain injuries is made even more complicated and confusing by the fact that the most sophisticated imaging techniques of the brain, CT scans and Magnetic Resonance Imaging (MRI), used to diagnose brain damage are best at detecting abnormalities of the gray matter and not precise enough to pick up subtle but real damage to the closely packed bundles of fibers making up the brain’s white matter.
The white matter remains the black hole of neurology. In many ways, sorting out damage to the fibers that connect the billions of brain cells is like trying to sort out a problem in the wiring of your computer. With current technology for both your computer and the brain it is difficult at best and in many cases almost impossible. A recent article in the newsletter Neurology Today described the medical problem:
A patient with a mild traumatic brain injury can pose a challenge to the neurologist—the clinical symptoms may suggest damage within the brain but the CT and MRI are usually normal.
In layman’s terms, a neurologist may have a great deal of clinical information and even suspicion about a potential brain injury, but there is no way to tell whether or not the brain has been structurally damaged if the CT scans and MRIs are read as normal. The open question with major changes in behaviors and alterations in cognitive functions following a potential brain injury is what it has always been, whether there is something wrong with the mind or basically something wrong with the brain.
There is no truly typical head injury. As simple an accident as sitting in a car and being hit from behind and abruptly and unexpectedly slamming your head back into a headrest can do it. For many, this perfectly simple everyday accident, with symptoms of lack of energy, lapses of memory, poor co-ordination, depression, and the “he or she are not themselves anymore,” qualifies as a mild Traumatic Brain Injury. These types of injuries, that make up over 85 percent of all brain injuries, are called “mild” because they are maddeningly difficult to confirm based on the fact that all the available brain scans do not display any prominent or focal abnormalities of the brain or surrounding tissues.
The neurologists and neuro-radiologists that see these patients literally have to put down “no significant brain injury” in their reports, making a definitive diagnosis or the ability to obtain damages from insurance companies virtually impossible. But these same physicians and researchers are currently pursuing neuro-chemical and serum markers of brain injury while the brain imaging experts are literally focusing on one of the probable areas of brain injury that up until the present time has been beyond observation or measurement, specifically, Diffuse Axonal Injury or DAI.
Diffuse Axonal Injury is a condition in which head trauma or a shock wave shears the delicate fibers that carry the electrical signals from one brain cell to the next, as well as forming the major nerves that leave the brain, forming the nerves of the spinal column. This type of axonal injury is notorious for eluding all the current imaging, blood, and spinal fluid evaluations, even if the patient is unconscious or severely confused following what has clearly been a head injury. What is clear is that damage to axons can unfold slowly or become worse over days, weeks, and with repeated so-called mTBIs, even over months and years.
It is this gap between symptoms and a definitive diagnosis of axonal injury that has led some psychologists dealing with veterans or active duty personal in Iraq and Afghanistan to a diagnosis of PTSD. By the patient having been exposed to multiple IEDS, or simply having been in a war zone, they recommend an anti-convulsive medication on a trial basis, suspecting the behavioral problems are a result of an mTBI.
If a medication that clearly treats major disruptions of brain function leading to seizures can be of benefit to patients with a diagnosis of PTSD, then one would have to consider a physical change within the brain itself, rather than a psychological diagnosis based on the stresses of the battlefield, even without any official record of history of exposure to a blast wave.
And, as so often happens in today’s medicine with its increasing emphasis on technology, there may now be a way to sort out the presence of axonal tears that might lead to a better diagnosis—that at least some of the symptoms of PTSD might indeed be the result of an injury to the brain itself rather than a damaged psyche.
Neuroscience may have finally begun to catch up with the some of the damages, as well as the fears and the heartaches, of going to war. It all began with the clinical observation that there are some characteristics of both concussive injuries and PTSD that are similar, if not identical.
In medicine, whenever you have similar symptoms, you can expect, or have to look for, similar causes. We know from studies of falls and car and motorcycle accidents, that short-term memory loss and poor concentration, irritability and anger, depression, headaches, dizziness, decreased executive functions such as planning or learning a new task, sleep problems, fatigue, and poor balance are all part of what is an mTBI. Even with these symptoms there might be no abnormalities noted on any of the routine imaging techniques. What is troubling is that 30 percent of patients with these symptoms will continue to have the same difficulties a year or more after the injury, indicating what may be both significant and persistent brain damage.
One of the characteristics of military personal with PTSD is poor short-term memory, irritability and anger, episodes of depression and anxiety, as well as fatigue, sleep problems, nightmares, states of hyper-arousal, and intrusive thoughts, including the re-experiencing of the past traumatic events. Clinically many of these symptoms are the same for both diagnoses.
In addition, some 50 percent of civilian patients with what are called “stun injuries” from blows to the head, have the same early and late symptoms as military patients with a diagnosis of PTSD, but these patients are found on CT and MRIs to have bruises of the frontal lobes of the brain.
Yet, the other 50 percent of patients with the same symptoms do not have any changes on the different imaging techniques and neurologists, in the face of the negative CTs and MRIs, have a tendency to call the problem psychological rather than physical. The open question for that 50 percent with stun injuries but normal CTs and MRIs is whether there is something wrong with the brain that has not been noticed on the various brain scans.
We are not supposed, nor are we allowed, to guess anymore in medicine. To have a physical disease you need a physical change. In order to have a diagnosis of strep throat, you do need to have a positive throat culture for Group A Strep. If you have chest pain a
nd are worried about a heart attack, but the angiogram shows open coronary arteries, you are not having a heart attack no matter the pain, even with a strong family history of relatives dying of heart attacks. In a real way, when it comes to the central nervous system, if you can’t see an abnormality or measure something that is different from the ordinary or the normal, then there is no organic disease and nothing is said to be physically wrong. That’s modern medicine and what patients have to put up with and what physicians are forced to do.
But for the brain at least, that kind of confusion and maybe even nonsense, may finally be coming to an end. If you haven’t heard of the Tensor MRI or the more technical term Diffusion Tensor Imaging or (DTI) you will, particularly if you are a soccer-mom or a father with a child playing high school or college football or any of the other sports where there is the possibility of head injuries resulting from helmet-to-helmet impacts.
Diffusion Tensor Imaging is an application of MRI technology that physically measures the direction of movement of individual water molecules throughout the brain’s axonal network, or white matter. In intact, undamaged brains the primary direction of movement of the water molecules is parallel to the nerve fibers, giving a precise, well-defined, and well-organized magnetic signal from an undamaged bundle of fibers. But when neuronal axons, even individual nerve fibers, are damaged, the movement of the water molecules throughout and along the fiber is disrupted, the molecules become less aligned even without any of the other usual signs of nerve damage, including bleeding or swellings. A change in the Tensor MRIs signal indicates damage, or at least some kind of physical disruption, along individual axons or within bundles of nerve fibers at that precise anatomical point of the signal shift.
Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 16