A permanent or relatively permanent impairment inHEAD INJURY (CHRONIC TRAUMATIC DISORDERS)brain functions resulting from a severe blow to the head. Chronic, or “post- traumatic,” disorders occur when the blow, or trauma, does lasting damage to the brain.The damage is usually confined to one area, and produces such symptoms as persistent headaches, dizziness, fatigue, irritability, anxiety, impaired memory, and defective concentration. Extensive damage may result in a general loss of intellectual ability, or produce specific defects, such as paralysis, aphasia or deafness, depending on the site of the destruction. Post-traumatic epilepsy occurs in 2 to 4 per cent of all cases, although some estimates are far higher. Seizures occur most commonly after penetrating wounds, and may take a Jacksonian, petit or grand mal form. The epileptic reactions sometimes occur months or even years after the injury took place. See EPILEPSY (SYMPTOMS AND TYPES).Personality changes are found in a small number of post-traumatic cases, perhaps 2 to 3 per cent. The less severe reactions are sometimes termed post-concussion syndrome, and are characterized by anxiety plus such symptoms as headache, oversensitivity to stimuli, vertigo, insomnia, inability to concentrate, and sudden emotional changes. These patients also have a reduced tolerance for alcohol, and frequently develop an intense “head consciousness.”The more severe reactions are sometimes classed as post-traumatic personality disorder. Adults who suffer from this condition show marked changes in attitude. Some of these patients become indifferent and withdrawn, but they are more likely to be irascible, petulant, impulsive, extremely selfish, and irresponsible. Older patients and those suffering from frontal lobe damage often show impaired memory with confabulation— that is, they fill in missing details with fictional material. See CONFABULATION,KORSAKOFF’S SYNDROME.Although children withstand head injury better than adults, their behavior is likely to be more disorganized and their reactions more extreme. A small percentage of children who have suffered head injury become disobedient, destructive, quarrelsome, distractible, and cruel. Like some post-encephalitic children, they are constantly restless, disruptive, and show little interest in school work. Many of them show intellectual impairment, and some have to be institutionalized.It is difficult if not impossible to determine the extent to which the personality changes are due to organic as opposed to psychological factors. Injured children usually suffer from headaches, dizziness, and sensitivity to light and noise. It is also known that brain injury tends to distort perception and to weaken the child’s ability to think abstractly, concentrate on problems, and carry out instructions. All these factors are due to organic damage. But they also show psychological reactions to these physical effects. They are deeply affected by the attitude of their parents or teachers to their handicap— for instance, if adults show impatience and lack of understanding, they are bound to feel resentful. They also react to their own feelings of frustration, inadequacy, and anxiety aroused by the sudden loss of key abilities. See MINIMAL BRAIN DYSFUNCTION.Among adults, the personality changes seem to be related to a number of different psychological factors. The most important is the premorbid personality. Post-traumatic disorders are most likely to develop in poorly adjusted or restricted, rigid individuals, even when the injury itself is relatively minor. In these patients the usual sequelae, such as perceptual disturbance, intellectual disability, physical symptoms, and headconsciousness, have a particularly disturbing effect. A number of other factors may also play a part in developing and fixing neurotic symptoms. Among them are family tensions, financial or occupational problems, anxiety about the future, fear of permanent defect, repeated examinations, and a desire for compensation. It is not surprising, therefore, that many people who have suffered head injuries become neurasthenic and hypochondriacal, and that in some instances the combined organic and psychological stresses bring latent psychotic tendencies to the surface.Treatment of chronic traumatic disorders takes three major forms: medical and surgical care, preventive psychotherapy, and carefully planned rehabilitation. Medical care is given as promptly as possible in order to repair lesions and stem hemorrhaging. Mild cases are released from the hospital and returned to work as soon as practicable. With other patients, preventive psychotherapy is given immediately in order to forestall neurotic reactions. This includes reassurance and emotional support, as well as explanation of the type of injury sustained.A rehabilitation program is launched as soon as possible. It consists not only of physiotherapy, recreational therapy and occupational therapy, but of re-education of the brain itself, so that new areas will take over lost functions. This is followed by a program of careful psychological testing and retraining aimed at preparing the patient for a return to vocational life. The specific nature of the rehabilitation program depends upon the location and severity of the injury, the patient’s motivation for recovery and resumption of work, the stability of his personality, and the possibility of returning to a favorable life situation. If these factors are generally positive, the prognosis will be good. If they are unfavorable or complicated by special factors such as alcoholism, drug addiction, arteriosclerosis, or severe emotional conflicts, it is likely to be poor.In a recent article (1968) Howard A. Rusk, director of the Institute of Rehabilitation Medicine, New York University Medical Center, summarized the results of a rehabilitation program involving 127 severely brain-injured patients. All were suffering from crippling disabilities due to brain hemorrhages, brain lacerations, contusions, or diffuse edema (swelling) resulting from automobile accidents, industrial accidents, assault, or attempted suicide. On the average, they had spent three weeks in coma and five weeks more in different stages of stupor, and their brain injury disabilities were in most cases compounded by fractures, amputations, lung damage, or other complications.In spite of the fact that most of these patients were not referred to the Institute until about a year after injury, all but 25 were judged feasible for rehabilitation. The program consisted of individualized training, including mat exercises, muscle re-education, gait training, and hand-eye activities, as well as bowel and bladder training and speech therapy where needed. An integral part of the program was retraining in everyday activities necessary to achieve independence. In addition, prevocational testing was provided to determine their ability to work, and the families were counseled and instructed on the management of the patient at home.In spite of the severity of the disabilities, the results of this “total approach” were most encouraging. Out of the 102 patients capable of participating, 55 were able to return to reasonably satisfactory and productive lives as housewives, students, executives, or artisans; 43 learned to dress and feed themselves independently; and 30 others required only moderate help.