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Can a brain injury change who we are?

 

Who we are, and what makes us “us” has been the topic of much debate throughout history. At the individual level, the ingredients for the unique essence of a person consist mostly of personality concepts. Things like kindness, warmth, hostility and selfishness. Deeper than this, however, is how we react to the world around us, respond socially, our moral reasoning, and ability to manage emotions and behaviours.

Philosophers, including Plato and Descartes, attributed these experiences to non-physical entities, quite separate to the brain. “Souls”, they describe, are where human experiences take place. According to this belief, souls house our personalities, and enable moral reasoning to occur. This idea still enjoys substantial support today. Many are comforted by the thought that the soul does not need the brain, and mental life can continue after death.

If who we are is attributed to a non-physical substance independent of the brain, then physical damage to this organ should not change a person. But there is an overwhelming amount of neuropsychological evidence to suggest that this is, in fact, not only possible, but relatively common.

The perfect place to start explaining this is the curious case of Phineas Gage.

Phineas Gage, after injury.
Originally from the collection of Jack and Beverly Wilgus, and now in the Warren Anatomical Museum, Harvard Medical School.

In 1848, 25-year-old Gage was working as a construction foreman for a railroad company. During the works, explosives were required to blast away rock. This intricate procedure involved explosive powder and a tamping iron rod. In a moment of distraction, Gage detonated the powder and the charge went off, sending the rod through his left cheek. It pierced his skull, and travelled through the front of his brain, exiting the top of his head at high speed. Modern day methods have since revealed that the likely site of damage was to parts of his prefrontal cortex.

Gage was thrown to the floor, stunned, but conscious. His body eventually recovered well, but Gage’s behavioural changes were extraordinary. Previously a well-mannered, respectable, smart business man, Gage reportedly became irresponsible, rude and aggressive. He was careless and unable to make good decisions. Women were advised not to stay long in his company, and his friends barely recognised him.

A similar case was that of photographer and forerunner of motion pictures Eadweard Muybridge. In 1860, Muybridge was involved in a stagecoach accident and sustained a brain injury to the orbitofrontal cortex (part of the prefrontal cortex). He had no recollection of the crash, and developed traits that were quite unlike his former self. He became aggressive, emotionally unstable, impulsive and possessive. In 1874, upon discovering his wife’s infidelity, he shot and killed the man involved. His attorney pled insanity, due to the extent of the personality changes following the accident. Sworn testimonies emphasised that “he seemed like a different man”.

Perhaps an even more controversial example is that of a 40-year-old school teacher who, in the year 2000, developed a strong interest in pornography, particularly child pornography. The patient went to great lengths to conceal this interest, which he acknowledged was unacceptable. But unable to refrain from his urges, he continued to act on his sexual impulses. When he began making sexual advances towards his young stepdaughter, he was legally removed from the home and diagnosed with paedophilia. Later, it was discovered that he had a brain tumour displacing part of his orbitofrontal cortex, disrupting its function. The symptoms resolved with the removal of the tumour.

Different personalities

Orbitofrontal cortex location.
Wikimedia/Paul Wicks

All these cases have one thing in common: damage to areas of the prefrontal cortex, in particular the orbitofrontal cortex. Although they may be extreme examples, the idea that damage to these parts of the brain results in severe personality changes is now well-established. The prefrontal cortex has a role in managing behaviours, regulating emotions and responding appropriately. So it makes sense that disinhibited and inappropriate behaviour, psychopathy, criminal behaviour, and impulsivity have all been linked to damage of this area.

However, changes after injury can be more subtle than those previously described. Consider the case of Mr. L, who suffered a severe traumatic brain injury after falling off a roof while supervising a building construction. His later aggressive behaviour and delusional jealousy about his wife’s apparent infidelity caused a breakdown in their relationship. To her, he was not the same man anymore.

Difficulties with emotion management like this are not only distressing, but are predictive of lower psychological adjustment, negative social changes and greater caregiver distress. Many brain injury survivors also suffer with depression, anxiety and social isolation, while struggling to adjust to post-injury life.

But with a growing appreciation of the relevance of emotional adjustment in rehabilitation, treatments
have been developed to help manage these changes. In our lab, we have developed the BISEP (Brain Injury Solutions and Emotions Programme), which is a cost-effective, education-based, group therapy. This addresses several common complaints of brain injury survivors and has a strong emphasis on emotion regulation. It teaches attendees strategies that can be used adaptively and independently, to help manage their emotions and associated behaviours. Although it is early days, we have obtained some positive preliminary results.

The ConversationFrom a neuropsychological perspective, it’s clear that who we are is dependent on the brain, and not the soul. Damage to the prefrontal cortex can change who we are, and though people have become unrecognisable from it in the past, new strategies will make a big difference to their lives. It may be too late for Gage, Muybridge and others, but brain injury survivors of the future will have the help they need to go back to living their lives as they did before.

Leanne Rowlands, PhD researcher in Neuropsychology, Bangor University

This article was originally published on The Conversation. Read the original article.

How and why the brain and the gut talk to each other

 

It’s widely recognised that emotions can directly affect stomach function. As early as 1915, influential physiologist Walter Cannon noted that stomach functions are changed in animals when frightened. The same is true for humans. Those who stress a lot often report diarrhoea or stomach pain.
We now know this is because the brain communicates with the gastrointestinal system. A whole ecosystem comprising 100 trillion bacteria living in our bowels is an active participant in this brain-gut chat.

Recent discoveries around this relationship have made us consider using talk therapy and antidepressants as possible treatments for symptoms of chronic gut problems. The aim is to interfere with the conversation between the two organs by telling the brain to repair the faulty bowel.

Our research found talk therapy can improve depression and the quality of life of patients with gastrointestinal conditions. Antidepressants may also have a beneficial effect on both the course of a bowel disease and accompanying anxiety and depression.

What are gastrointestinal conditions?

Gastrointestinal conditions are incredibly common. About 20% of adults and adolescents suffer from irritable bowel syndrome (IBS), a disorder where abdominal discomfort or pain go hand-in-hand with changes in bowel habits. These could involve chronic diarrhoea and constipation, or a mixture of the two.

IBS is a so-called functional disorder, because while its symptoms are debilitating, there are no visible pathological changes in the bowel. So it is diagnosed based on symptoms rather than specific diagnostic tests or procedures.

People with chronic gut conditions can experience severe pain that affects their quality of life.
from shutterstock.com

This is contrary to inflammatory bowel disease (IBD), a condition where the immune system reacts in an exaggerated manner to normal gut bacteria. Inflammatory bowel disease is associated with bleeding, diarrhoea, weight loss and anaemia (iron deficiency) and can be a cause of death. It’s called an organic bowel disease because we can see clear pathological changes caused by inflammation to the bowel lining.

Subtypes of inflammatory bowel disease are Crohn’s disease and ulcerative colitis. Around five million people worldwide, and more than 75,000 in Australia, live with the condition.

People with bowel conditions may need to use the toilet 20 to 30 times a day. They also suffer pain that can affect their family and social lives, education, careers and ability to travel. Many experience anxiety and depression in response to the way the illness changes their life. But studies also suggest those with anxiety and depression are more likely to develop bowel disorders. This is important evidence of brain-gut interactions.

How the brain speaks with the gut

The brain and gut speak to each other constantly through a network of neural, hormonal and immunological messages. But this healthy communication can be disturbed when we stress or develop chronic inflammation in our guts.

Stress can influence the type of bacteria inhabiting the gut, making our bowel flora less diverse and possibly more attractive to harmful bacteria. It can also increase inflammation in the bowel, and vulnerability to infection.

Chronic intestinal inflammation may lower our sensitivity to positive emotions. When we become sick with conditions like inflammatory bowel disease, our brains become rewired through a process called neuroplasticity, which changes the connections between the nerve signals.

Anxiety and depression are common in people suffering chronic bowel problems. Approximately 20% of those living with inflammatory bowel disease report feeling anxious or blue for extended periods of time. When their disease flares, this rate may exceed 60%.

Interestingly, in a recent large study where we observed 2,007 people living with inflammatory bowel disease over nine years, we found a strong association between symptoms of depression or anxiety and disease activity over time. So, anxiety and depression are likely to make the symptoms of inflammatory bowel disease worse long-term.

It makes sense then to offer psychological treatment to those with chronic gut problems. But would such a treatment also benefit their gut health?


Gut feeling: how your microbiota affects your mood, sleep and stress levels


Inflammatory bowel disease

Our recent study combined data from 14 trials and 1,196 participants to examine the effects of talk therapy for inflammatory bowel disease. We showed that talk therapy – particularly cognitive behavioural therapy (CBT), which is focused on teaching people to identify and modify unhelpful thinking styles and problematic behaviours – might have short-term beneficial effects on depression and quality of life in people with inflammatory bowel disease.

But we did not observe any improvements in the bowel disease activity. This could be for several reasons. Inflammatory bowel disease is hard to treat even with strong anti-inflammatory drugs such as steroids, so talk therapy may not be strong enough.

Talk therapy may only help when it’s offered to people experiencing a flare up in their disease. The majority of the included studies in our review were of people in remission, so we don’t know if talk therapy could help those who flare.

On the other hand, in our latest review of 15 studies, we showed antidepressants had a positive impact on inflammatory bowel disease as well as anxiety and depression. It’s important to note the studies in this review were few and largely observational, which means they showed associations between symptoms and antidepressant use rather than proving antidepressants caused a decrease in symptoms.

Studies show talk therapy improves the symptoms of irritable bowel syndrome.
from shutterstock.com

Irritable bowel syndrome

When it comes to irritable bowel syndrome, the studies are more conclusive. According to a meta-analysis combining 32 trials,
both talk therapy and antidepressants improve bowel symptoms in the disorder. A recent update to this meta-analysis, including 48 trials, further confirmed this result.

The studies showed symptoms such as diarrhoea and constipation improved in 56% of those who took antidepressants, compared to 35% in the group who received a placebo. Abdominal pain significantly improved in around 52% of those who took antidepressants, compared to 27% of those in the placebo group.

Symptoms also improved in around 48% of patients receiving psychological therapies, compared with nearly 24% in the control group, who received another intervention such as usual management. IBS symptoms improved in 59% of people who had cognitive behavioural therapy, compared to 36% in the control group.

Stress management and relaxation were found to be ineffective. Interestingly, hypnotherapy was also found effective for bowel symptoms in 45%, compared to 23% of control therapy participants.

What now?

Better studies exploring the role of talk therapy and antidepressants for symptoms of inflammatory bowel disease need to be conducted. We should know in a few years which patients are likely to benefit.

The ConversationIn the meantime, there is enough evidence for doctors to consider referring patients with irritable bowel syndrome for talk therapy and antidepressants.

Antonina Mikocka-Walus, Senior Lecturer in Health Psychology, Deakin University

This article was originally published on The Conversation. Read the original article.