Forensic Updates

Challenges to Understand and Unravel the Complexity of Mild Brain Injury: Why Is This So Difficult?

Dr. Sam Goldstein

A number of weeks ago I had the opportunity to testify as a forensic neuropsychology expert on behalf of a plaintiff whose treating providers had diagnosed, and for a number of years, been treating him for problems related to a mild traumatic brain injury. Although the majority of mild traumatic brain injuries do not cause significant, adverse long-term life changes, for a small percentage – perhaps eight to ten percent – for reasons that remain unexplained, such injuries can result in a significant disruption in vocational and personal life. This was the case for this particular gentleman. During the course of my testimony and subsequent questioning by the insurance company’s retained attorney, it once again became apparent to me how little even educated professionals understand about the implication of such injuries and the small group of people experiencing a Persistent Post-Concussive Disorder. In fact, the retained insurance company neuropsychological expert insisted that the severity of this man’s problems, even taking into account the complete absence of such problems pre-accident in this man’s life, precluded the accident as the primary cause of his struggles. Astoundingly this professional put forth the opinion that long resolved childhood issues were the cause of current problems!

It is imperative that the general population develop a better understanding of the potential consequences of a mild traumatic brain injury. In this article I will briefly review the global incidence of brain injury, typical consequences, and offer my opinions as to the challenges in understanding the struggles some individuals experience chronically after such injuries.

Brain injuries continue to be a significant public-health concern globally, affecting millions of people each year. These injuries range from mild to low moderate severity for the majority of affected individuals. Yet, they can have far-reaching consequences for some individuals, their families, and society as a whole. While the medical and neuropsychological community has made significant strides in understanding brain injuries, the complexity of the brain (an average of 86 billion neurons or moving parts) and the varied manifestation of these injuries makes it challenging for the typical lay person to grasp their implications fully.

Brain injuries encompass a wide range of traumatic and non-traumatic events that disrupt the normal functioning of the brain. The World Health Organization estimates that approximately sixty-nine million people worldwide sustain a traumatic brain injury each year. This figure highlights the scale of the problem and its global impact on affected individuals, their families, and the community. It is also my opinion that this statistic likely underestimates the true incidence of brain injuries, as many cases of more mild injuries go unreported or undiagnosed due to varying health-care access and at times the stigma associated with mental health challenges.

The incidence of brain injury varies across different age groups, regions, and countries. Among children and young adults, falls and sports-related injuries are the leading causes of brain injuries. In adults, incidents such as motor-vehicle accidents and falls are more prevalent. Additionally, many regions in the world with limited access to health care and infrastructure likely have higher rates of brain injury due to delayed or inadequate availability of medical care.

Consequences of Mild-to-Moderate Brain Injury

Mild-to-low moderate brain injuries are among the most common types of brain injury, accounting for the majority of all cases. While often referred to as concussions, these injuries should not be underestimated due to their less-severe presentation. The consequences of mild-to-low moderate brain injuries can be far reaching and impactful on an individual’s physical, cognitive, emotional, and social functioning. They can impact family relations, vocational activities, and work. These consequences appear to fall into five categories:

  1. Physical. Mild-to-low moderate brain injuries can lead to a range of physical symptoms, such as headaches, dizziness, nausea, and fatigue. While these symptoms are temporary for many, some individuals experience persistent physical issues affecting their ability to perform everyday personal and vocational activities.
  2. Cognitive. Cognitive impairments are common following mild-to-low moderate brain injuries. Individuals typically do not lose ability but rather struggle with the efficiency with which they can apply their abilities. I refer to this as cognitive efficiency. They often experience difficulty with attention, concentration, working memory, and problem-solving. These deficits can exert a significant adverse impact on academic and occupational functioning as well as interfere with daily-life tasks.
  3. Emotions and Behavior. Mild-to-low moderate brain injuries can affect emotional regulation and behavior. Mood swings, irritability, anxiety, and depression are common emotional consequences of brain injuries. Further, as many individuals with these injuries attempt to return to normal life, their frustration can, in and of itself, fuel depression and anxiety. These changes often lead to social isolation and feelings of alienation. Some individuals experience a decrease in their emotional threshold and an increase in their intensity of response, leading to patterns of irritability and disruptive behavior.
  4. Social. The consequences of mild-to-low moderate brain injuries extend to the social realm. Affected individuals often face challenges in maintaining relationships, participating in social activities, and reintegrating into the community. These cognitive and emotional changes often lead to social isolation and increased feelings of alienation.
  5. Post-Concussive Syndromes. Some individuals with mild-to-low moderate brain injury progress to post-concussion and persistent post-concussion. This is characterized by persistent symptoms lasting beyond the typical recovery period. Post- and persistent post-concussive disorders are often debilitating, affecting the individual’s ability to return to work, school, or engage successfully in everyday activities.

When injuries beyond the brain affect chronic body pain, or the experience of the accident event results in adverse emotional changes such as Post-Traumatic Stress Disorder, it often appears that these five areas are even further adversely affected.

Challenges to Understanding Mild-to-Low Moderate Brain Injuries

Despite the prevalence of mild-to-low moderate brain injuries and their profound consequences, multiple factors appear to contribute to the challenges the general public has in understanding and appreciating their impact fully. These include:

  1. The Invisible Nature of Injuries. Unlike many physical injuries, brain injuries are often referred to as “invisible,” as the damage occurs internally. This invisibility often leads to a lack of empathy and understanding from others, as individuals with mild-to-moderate brain injuries “look just like everyone else.”
  2. Delayed Onset of Symptoms. Although it is the case that direct symptom consequences from a brain injury often are present to a greater degree the closer to the accident and may diminish over time, the consequences of such symptoms, particularly as affected individuals attempt to return to normal life, can lead to reports of increased problems with memory, concentration, and emotional regulation. For that reason, however, symptoms can take hours, days, or even weeks to appear, making it challenging to connect the symptoms with the initial injury.
  3. Varied Presentation. Mild-to-moderate brain injuries can present differently in different individuals. This makes it challenging to identify a standardized set of symptoms. Some individuals can recover relatively quickly while others may experience persistent symptoms for an extended period. Particularly in litigation, there is a tendency to assume that if most individuals recover within a given period of time, then anyone remaining symptomatic must have some other unrelated problem.
  4. Misdiagnosis and Underreporting. Brain injuries are often misdiagnosed or underreported, particularly in the case of mild injuries. The lack of awareness among health-care professionals and the public often leads to delayed or inadequate treatment, exacerbating over time the consequence of a brain injury.
  5. Stigma and Stereotype. Stigma and stereotype surrounding brain injuries can hinder open discussion and support for affected individuals. Although in the last twenty years, with the recognition of military and sports-related injuries, this stigma and stereotype has improved, there continues to be a societal expectation that individuals with brain injury should “just get over it.” This undermines the severity of the injury and its ultimate consequences.
  6. Overlooking Long-Term Effects. Mild-to-moderate brain injuries can have lasting effects that extend beyond the acute phase of injury. However, the focus is often placed on severe brain injuries, leading to insufficient attention to the ongoing needs of individuals with milder injuries, particularly over the course of a lifetime.

Brain injuries, particularly mild-to-low moderate traumatic brain injuries, are a significant global health concern, with far-reaching consequences. The impact of these injuries on individuals’ physical, cognitive, emotional, familial, vocational, and social functioning should not be underestimated. Overcoming the challenges in brain injuries requires increased awareness, early detection, and improved support systems for affected individuals. Our society is increasingly better educated about brain injuries, particularly mild-to-moderate injuries. However, it is still the case that on a routine basis many medical and neuropsychological experts continue to “believe” the fantasy that everyone with such injuries recovers and, if they don’t, it must be for some other non-injury reason.

By acknowledging the wide-ranging consequences of brain injuries, we can continue to strive to improve diagnosis, treatment, and societal support, ensuring a better quality of life for those affected by these injuries. Researchers are increasingly focusing on valid and reliable physiological measures reflecting changes in the brain after injury consistent with the research that has been and continues to be completed for individuals with cardiac arrest.

Finally, I have repeatedly been struck by the comments of family members of injured individuals whose opinions about mild-to-moderate brain injury have changed once they have had the experience of living with someone suffering from such an experience. As a treater and forensic expert I listen and place high value on their observations.◆