Wednesday, 23 May 2012

Brain injury and sexuality

The North American Brain Injury Society publication, Brain Injury Professional, has a wonderful issue dedicated to brain injury and sexuality.

The articles in this publication go beyond the usual neuropsychological preoccupation with how to deal with sexually disinhibited behaviours. As Tina Trudel, guest editor of the issue writes,  "Sexuality is a life affirming gift that enriches all of us. How we share love, experience passion and engage in sexual activity are unique, vital aspects of who we are. Brain injury rehabilitation seeks to support and empower each individual to reach their full human potential, a potential that rests on the cornerstones of our capacity to work and to love (not necessarily in that order...)." (p. 6).

The five articles in the issue talk about integrating sexuality in rehabilitation; disability and sexual expression (including lots of practical hints for different forms of cognitive and motor disability); promoting sexual health in adolecents with brain injury; sexual intimacy after brain injury; and behavioural interventions for sexual disinhibition after brain injury. Being comfortable and informed in discussing these issues with patients and their partners is an important, but often neglected part of clinical care.

The publication is highly recommended reading for all neuropsychologists who are interested in providing informed patient-centered care for their clients, whatever their age or disability.

Sports Concussion readings

This is a controversial and very current topic.

Thanks to Arthur Shores for providing these links to guidelines and resources on sports concussion:

There are also a couple of statements by neuropsychological groups in the US:

And the National Academy of Neuropsychology had a recent NAN Bulletin article about the issue

and a video and other resources at: 

There will be a meeting in Zurich later this year, to update the Zurich guidelines - but there's plenty of reading to do in the meantime!  

Australian House of Representatives Inquiry into Dementia: early diagnosis and detection

There are a number of fascinating submissions to this recent inquiry, viewable at:

It is interesting to see the number of submissions that promote a particular service or service model.
I haven't read all of them yet, but the model described by Professor Philip Morris (#4) sounds excellent, taking a rehabilitation approach to dementia care. The submission made by my colleagues at the community dementia team (#14) describes an initiative that has been beneficial in a community setting. The Tasmanian DHHS submission (#41) has some very sobering statistics for my home state, and the federal department of health submission (#89) is also sobering.

I like the practical recommendations made by the Victorian CDAMS submission (#39). The Victorian Office of the Public Advocate (#3) wrote an interesting submission in terms of decision-making capacity and dementia, and Professor Jillian Krill (#6) argued about the vital importance of correct diagnosis of dementia, if targeted treatments are going to become available. The practicalities of getting postmortem examinations on people with dementia are challenging, but we need to have the postmortem gold standard available to clarify the relationship between clinical symptoms and pathology if targeted pharmacological therapies are going to be developed.

The Australian Psychological Society wrote a good submission with the assistance of members of the College of Clinical Neuropsychologists (#50), and I contributed my own submission in the hope that there would be at least one neuropsychologist's voice heard by the enquiry (#46). My submission isn't perfect, but hopefully it will back up the poignant voices of the various consumers and carers who talked about the difficult time between development of symptoms and diagnosis.

In case I'm called to give evidence to the Inquiry, Any suggestions on succinct things I can say to demonstrate the efficacy of neuropsychologists in early diagnosis and interventions for dementia would be appreciated.

Tuesday, 15 May 2012

Neuropsychologist self-care

I found a touching and useful article today.

It's by John O'Brien and is called Wounded Healer: Psychotherapist Grief Over a Client's Death
You'll find a link to the abstract and citation at

O'Brien concludes that "A psychologist's grief over a client's death can be especially difficult if the psychotherapy has triggered the psychologists' past and/or present grief. If these reactions are not appropriately managed, they can hamper and ultimately impair present and future clinical practice. If, on the other hand, we learn to manage our wounds, we can use these wounds to better serve our clients. Appropriate self-care and consultation with colleagues are essential components of providing ethical and effective care to those who are critically or terminally ill." (O'Brien, 2011, p. 242).

The Australian Psychological Society says that "As a profession we need to support ourselves and our colleagues to seek out preventative and early interventions and to de-stigmatize help-seeking behaviour."

I've had a look on the web for neuropsychologist self-care resources, and have only found articles about neuropsychologists assessing self-care abilities in others!!!

I suspect that self-care for neuropsychologists is somewhat different compared to psychologists engaged in psychotherapy. We deal with patients with devastating acquired injuries or incurable progressive diseases. The majority of us don't follow patients through with regular therapy sessions. We help provide answers to their questions, hopefully provide therapeutic feedback and recommendations, and then send them on their way, with a sense of satisfaction of having helped shed light and knowledge where there was uncertainty and anxiety.

But sometimes our personal lives raise issues that intersect with our professional roles, or we see patients who break through our defences, who affect us emotionally. So what are the strategies neuropsychologists use to care for themselves? Please use the comments box below!

Wednesday, 2 May 2012

Why is neuropsychology important? A personal view.

I wrote the following words in 2009, but never shared them with more than a few friends. I'd like to post them here now.

My elder son’s Year One class is looking at occupations this term. On a big sheet of butcher’s paper on the wall of their room is a list of occupations generated by his class – nurse, doctor, builder, truck driver, farmer, princess, architect, soldier, celebrity – the usual, and not-so-usual interests of 6 and 7-year olds. Throughout the term, they’ll be adding as many occupations as they can, and my son has already added ‘neuropsychologist’. He had to get his teacher to write it out so that he could trace over top, but he has the definition down pat. “It’s someone who helps people with brain problems, Mum”.

I’m going to have a neuropsychology stand at my son’s school science night, and talk to the Year Ones about being a neuropsychologist, because I think it is incredibly important. In his insatiable appetite for bedtime stories, he’s begun to soak up stories about Broca and Tan, Karl Wernicke, and Phineas Gage and his tamping iron. He can even sing some neuroanatomy with the first verse of Pinky and the Brain’s brain song, (to the tune of ‘Campdown races’):

Neocortex, frontal lobe
brain stem, brain stem
hippocampus, neural node,
temporal lobe
cerebellum left
cerebellum right
synapse, hypothalamus,
striate and dendrite’

Though he still tends to sing ‘try and get it right’ for the last line.
(for the full animation, see ).

Why is clinical neuropsychology so important in this time of global financial crises and climate change? And why am I talking about it to my son, and his class, and maybe some of their parents? It’s because neuropsychologists help people from all ages and walks of life, and because we have specialised knowledge and skills that help us to help others understand what is happening when someone’s brain isn’t “working properly.”

My recent personal experience has shown me just how important neuropsychological knowledge is, and how we can’t assume that our medical colleagues will necessarily understand things the way we do.

My father has only recently become well enough to return home from Victoria to Tasmania, after a planned 3-week stay in hospital for some checkups and reconditioning became a 3-month admission. Dad has a history of normal pressure hydrocephalus (first diagnosed and shunted in 2004, followed by a shunt revision in 2005), TIAs, and angina in 2007. He became increasingly irritable and lethargic over the last few months of 2008, often falling asleep in his armchair after breakfast, and his gait fluctuated widely. We brought him to Melbourne to be reviewed by his neurosurgeon, who felt that his NPH wasn’t contributing to the clinical deterioration. Then we had him seen by a cardiologist, who did an angiogram and discovered extensive coronary artery disease, which required 6 stents, inserted over two sessions.

Dad developed a delirium after the first angiogram, and declined further after transfer to a geriatric unit. He became disoriented to place and time, and developed mildly paranoid delusions, nocturnal agitation, and occasional visual hallucinations. I was struck by how distressing this was to my parents, and also to me, even though I knew what delirium was. Perhaps it was even more distressing to me because I was reading about management and prognosis in delirium, and because no-one could tell me why he’d declined, other than speculating on toxicity from the dye used in the angiography. While cognitive decline after CABG is well-known, especially in patients with compromised cerebral functioning beforehand, I couldn’t find much through my distressed search of the literature to suggest that a toxic reaction to angiography dye was a common reaction, and even his cardiologist was surprised. I felt that we had to fight to convince the staff that he’d suffered an acute decline in functioning from being independent, albeit mildly impaired, in January to needing maximal assistance with transfers and ADLs in February. It wasn’t until I found him staring and unresponsive in his chair one day that I felt they were beginning to take us seriously. His mobility declined to the point that a hoist was needed for transfers, his bed was lowered to the floor, and we had him returned to the private hospital under the care of neurologist. The neurologist changed some of Dad’s medications, to remove any that might lower his sodium, and restricted his fluid intake in order to address the hyponatremia that a registrar had thought was not serious enough to be treated. While sodium levels <120 with cerebral impairment is considered to be severe hyponatremia, the neurologist explained that levels below 130 in an elderly person can cause problems. Over the weeks, with an increase in sodium levels from 125 to 134 (just below the normal range), Dad improved enough to be transferred back to hospital in Tasmania, where he is getting regular visits from family and friends. Unfortunately, his sodium levels have continued to fluctuate, and it looks like it will take a long time for him to be well enough to return home.

Having been through all this has given me a concerning insight into how difficult it must be for lay people to negotiate the health system, and how a neuropsychological perspective can make a difference to a patient’s care and outcome, even without doing any formal testing. If I, as a neuropsychologist, felt that I struggled to be heard, and to have my father’s changed status recognised, how difficult must it be for people without my knowledge? Even the backup of my husband, a member of the medical fraternity, didn’t help me overcome the feeling that I was perceived by some members of Dad’s treatment team to be making an inordinate fuss about my father’s condition. I found myself wishing I could slip into the “grateful relative of patient” role, where it is comfortable and comforting to accept the wise advice of the medical staff, but I just couldn’t understand why he’d declined like that, and I couldn’t accept that it was a normal thing to happen to an elderly man. Just because delirium is common in elderly people doesn’t mean that it’s “normal.” I wanted someone to give me reasons for the changes that made sense, and I felt that I had to fight to have them understand that in three weeks, this wonderful, loving, kind man had gone from being oriented to place and independent in ADLs to being disoriented, visually hallucinating, somnolent, distressed, agitated, catherterized, occasionally inappropriate, impulsive, and needing assistance with everything. My father-in-law died last year, 3 years after a stroke that saw him put prematurely into a nursing home, because we trusted the medical opinion that he wouldn’t benefit from rehab. He wasn’t even given the chance to try. He languished, with increasing contractures, even on his unaffected side, because the physio thought he was a “lost cause.” Passive mobilization exercises from a private physio improved his contractures to the point that he was able to sit comfortably in the few weeks before he finally passed away. I wasn’t going to let that happen to Dad.

These experiences have taught me the vital importance of listening carefully to the patient and their families, and of not accepting glib explanations from overworked medical staff who do not necessarily have the time to listen, and then think, about what they are being told. If we hadn’t had Dad reviewed by the neurologist, he’d probably be in a nursing home, or worse, right now, and my heart would be broken. Being a neuropsychologist doesn’t save you from that, it seems.

Being a neuropsychologist does help you to step back and look at the big picture for each person you see – what is their background, their highest level of functioning, their most recent level of functioning? What was the onset and course of their condition? How are they now? What is their medical history, what are their medications, how are all these factors interacting to produce the current clinical issue?

Even without access to our tests, we are able to make a meaningful contribution to the care of patients, because of the way we’re trained to think, and to formulate an understanding of how medical, neurological, psychological, and social factors are contributing to a person’s condition. We may not directly “save” lives, but we can have a huge impact on quality of life. We can also help their families and caregivers understand and deal with their condition, and I know my recent experience is going to make me even more sensitive to how carers feel and are coping.

Disorientation and lack of insight are things encountered regularly in practice with elderly people, but I’d never really felt how distressing it can be to patients or family members since becoming a neuropsychologist. But if I remember way, way back, I remember being awed and bewildered as a child when a dear, elderly family friend spent her last few months in a hospital bed, asking for her Father to come back from the top paddock, wondering if Mother had cooked the scones yet, and only recognizing those she had known for more than 40 years. It was that sense of powerlessness and not understanding that drew me to neuropsychology, because I wanted to help people understand these incomprehensible tricks of the mind.

The contribution of clinical neuropsychologists to healthcare is unique – our training in neurological and psychiatric disorders, in neuroanatomy and cognitive psychology, in normal and abnormal cognitive development across the lifespan, in psychometrics and behavioural observation, and psychology in general, give us an ability to understand a person’s presentation that is not held by any other healthcare professional. There aren’t enough of us to meet the current demand, but there is a role for us in every aspect of acute and chronic healthcare, in prevention and diagnosis and treatment, in admission and discharge planning. We need more training programs and clinical placements in each state of Australia, we need more publicly funded services so that we can help the public. We need to educate the public, and politicians, about what we do. Clinical neuropsychology is important.


PS Dad finally returned home after 6 months in hospital. It took 9 months of fluid restriction for his sodium levels to return to normal, and he was able to move around the home and participate in a quiet but fulfilling family and social life. He accompanied Mum to choir practice and started sharing his beautiful voice at choir functions - his renditions of 'As Time Goes By' and 'Night and Day' were gentle and relaxed, and music gave him pleasure up to the end. We moved back to Tasmania to be closer to him at the start of 2010, but I'll save that story for another time.