We have this client.
His family says that he’s just not the same guy he’s always been. He’s extremely sensitive and gets angry at the slightest offense.
He can’t concentrate. His wife is frustrated because he can’t remember simple errands. Sometimes his mind wanders so much that he gets lost, or forgets what he was supposed to be doing.
Every day, he wakes up feeling overwhelmed by the idea of getting dressed, showered, and out of the house. Every night, he takes a sleeping pill. He has no appetite – food doesn’t taste good any more. He chugs Coke all day long, just to keep his eyes open.
He’s afraid of losing his job. He’s afraid of destroying his relationship. He struggles with self-esteem. And he’s convinced that there’s no way out.
So, what’s your first thought? Depression? Anxiety?
Did any of you think brain injury?
Two clients, same symptoms, different causes
The truth is, this isn’t one client. It’s actually two. One survived a pretty serious traumatic brain injury after falling off a roof. The other developed depression and anxiety after he lost his house to foreclosure and had to take a significantly lower paying job.
They use the same words and phrases to describe how they suffer. They share the same daily challenges and frustrations. Two distinct situations that ultimately meet on the same long and difficult path.
Perception is the key
However, the perception each man has of himself, the way he talks to his doctor, how his doctor responds, and the way each man approaches recovery? That is very different. One man is considered to have a physical injury in his brain – he sees a neurologist. The other is considered to have a mental illness – he sees a psychologist and a psychiatrist.
Even though they struggle with the same symptoms and daily challenges, their perception of how and why things are wrong changes everything.
Brain injury = Depression and Anxiety?
The person with a brain injury knows that there is something physically wrong. No one can see the small scar in his scalp, but he knows that the injury is there. What frustrates him is when his doctors talk about antidepressants and therapy – as if he had a mental disorder, and not a brain injury. He feels misunderstood and refuses to try anything.
The person diagnosed with depression and anxiety believes that his problems are mental. He senses that everyone thinks he can pull himself together, if only he would try hard enough. It frustrates him to hear his doctors talk about mindfulness and stress-reduction when he can’t get past the feeling that there’s something physically wrong with him. He feels like a failure for not getting better.
Stigma’s intersection between brain injuries and mental illness
Is the stigma of brain and mental health problems perpetuated because of the boundaries that come between medical specialties? The terms “psychological,” “neurological,” and “psychiatric” all live in the same zip code in the brain, so what exactly is the point of pigeon-holing each person? Is one man’s case solely neurological, and the other psychological? Let’s consider.
Chemical changes and physical damage in the brain
The traumatic brain injury client experienced an injury as a result of a physical force to his head. His brain suffered from major chemical changes and physical damage that destroyed some neurons, and forced others to re-route and compensate. These brain changes resulted in depression, anxiety, sleep problems, concentration and memory impairment, and fatigue. {{1}}
The client who experienced a traumatic loss and chronic stress also experienced major chemical changes in his brain. These chemical changes will eventually cause physical damage to parts of his brain, forcing some neurons to re-route and compensate. {{2}} These changes may be responsible for the depression, anxiety, sleep problems, concentration and memory impairment, and fatigue.
Physical damage to the brain due to depression and anxiety
That means there is probably a biological basis for his depression and anxiety. Could it also mean that some cases of depression and anxiety are a type of brain injury caused by trauma and chronic stress?
Scientists aren’t really saying so directly, but their research still supports the idea. Several studies show physical damage in certain areas of the brain of chronically depressed or anxious people. {{3}} {{4}} Other studies show that antidepressants can help generate new brain cells {{5}}, and promote the kind of chemicals (such as BDNF, brain-derived neurotropic factor) {{6}} needed to reverse brain damage – regardless of whether a person is depressed and anxious or not. {{7}} {{8}}
Depression and anxiety not mental illnesses?
What if we stopped calling depression and anxiety mental illnesses, and instead called them brain disorders? What if we went further and acknowledged that stress and trauma causes injury to the brain that results in symptoms such as depression, anxiety, sleep problems, and so on?
That shift in perception would equalize my two clients somewhat, and help explain why both of them suffer in such a similar way. They’re both struggling with a type of injury to the brain. They both might be treated for the resulting symptoms.
An imaginary conversation
I imagine a conversation between a patient and her general practitioner:
Patient: I lost my job several months ago, and my life has been incredibly stressful. I wake up feeling so worried and scared. I think about what I had and it makes me feel angry and sad to have lost it, and to be in this position now. I can’t stop thinking this way. I can’t sleep at night. I don’t even feel like seeing friends any more. It’s causing a lot of problems. I just don’t feel good. I don’t know how I’m going to pull out of this.
Doctor: It sounds like you might be experiencing a type of brain disorder caused by the trauma and stress of losing your job. Significant, long-term stress like you described, can cause physical damage to the brain. It’s no wonder it feels impossible to pull out of it – that kind of chronic stress can reduce your brain’s resources.
What I’d like to do is put you in a treatment plan that helps reverse the injury to the brain. Let’s start by talking about an antidepressant. We know that antidepressants regenerate brain cells, especially in parts of the brain that are vulnerable to stress. The antidepressant will also help increase certain chemicals in the brain that have been shown to reverse signs of depression and memory problems. It might also help you manage stress better. I have to warn you that it could take six to eight weeks before there’s any significant new brain cell growth, so you need to be patient.
Second, we need to start some cognitive and physical therapy for your brain. The cognitive therapy will help strengthen some of the brain functions you’ll need to better cope with stress. The physical therapy involves light cardiovascular exercise that will promote blood flow to your brain, and will also increase the brain chemicals that will help heal the damaged areas of the brain. I’ll refer you to two specialists, but I want you to start both therapies at a slow pace. You don’t want to overtax your brain too soon. Work up to it slowly.
Most importantly, we need to address your sleep. Your injured brain can’t heal unless it has plenty of sleep, so I’d like to start you off with a sleep medication for now, and we’ll wean you off of it as you start to get better. I need to see you in four weeks to make sure you’re resting and things aren’t getting worse. In the meantime, be patient. This kind of stress-related injury is serious, and you need do as much as you can to support your brain’s recovery.
Openness to new ideas and a change of perception
This is just a theory. But remember, so is the idea that depression results from a chemical imbalance. We’re just not at a place in brain science that we can know anything for sure. So, we might as well be open to new ideas. {{9}}
If you viewed your depression and anxiety as a physical injury to your brain, would that change the way you see yourself and your illness? Would it change the way you talk to your doctors? Would you feel validated instead of misunderstood?
Could you more easily compare yourself to someone who had, say, a major knee injury? Would you be able to approach medication and therapy in the same way a person with a knee injury does—with a little more patience and endurance? Would your family and friends be more understanding?
Would you be kinder to yourself?
Marie Rowland is a neuroscientist, writer, and patient advocate. She founded EmpowermentAlly to help promote patient empowerment in people who have mental illness or a brain injury. You can find her at EmpowermentAlly and you can help support mental health services at Fundable – EmpowermentAlly.
Last Update: October 3, 2012
[[1]] Riggio, S. Traumatic. Brain injury and its neurobehavioral sequelae. Retrieved October 1, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/21093680 [[1]]
[[2]] Djordjevic A, Adzic M, Djordjevic J, & Radojcic MB. Chronic social isolation suppresses proplastic response and promotes proapoptotic signaling in prefrontal cortex of Wistar rats. Retrieved October 1, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/20623537 [[2]]
[[3]] Takahashi T, Yucel M, Lorenzetti V, et al. Volumetric MRI study of the insular cortex in individuals with current and past major depression. Retrieved October 1, 2012 from http://www.nbi.nlm.nih.gov/pubmed/19540599 [[3]]
[[4]] Hettema JM, Kettenmann B, Ahluwalia V, et al. Pilot multimodal twin imaging study of generalized anxiety disorder. Retrieved October 1, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/21994092 [[4]]
[[5]] Boldrini M, Hen R, Underwood MD, et al. Hippocampal angiogenesis and progenitor cell proliferation are increased with antidepressant used in major depression. Retrieved October 1, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/22652019 [[5]]
[[6]] The best short introduction to Brain-derived neurotrophic factor can be found at Brain-derived neurotrophic factor [[6]]
[[7]] Kaplan GB, Vasterling JJ, & Vedak PC. Brain-derived neurotrophic factor in traumatic brain injury, post-traumatic stress disorder, and their comorbid conditions: Role in pathogenesis and treatment. Retrieved October 1, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/20679891 [[7]]
[[8]] Lee MM, Reif A, & Schmitt A.G. Major Depression: A role for hippocampal neurogenesis? Retrieved October 1, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/22903751 [[8]]
[[9]] To learn more about the history and current state of treatment for depression, read “Post-Prozac Nation” [[9]]
