The Emotional, Psychological, and Financial Impact of Traumatic Brain Injury on Patients and Families

Concussion Symptoms & Early Assessment

0:03

Stewart Cohen: In the age of the internet, people could be looking at this videotape because they’ve just taken a loved one to the emergency room after a concussion, with or without a period of loss of consciousness. Based on your experience, what are the kinds of symptoms that people should be looking for after a concussion?

Dr. Thomas Swirsky-Sachetti: Well, in the cognitive sphere, it would be confusion—just not being as sharp. People describe this cloudy feeling. The way that I describe it to family members, it’s kind of like one of those snow globes: when you shake it up, it gets snowy and blurry, and that’s what happens to the brain. Eventually, that snow settles and it becomes clearer. So that sense of cloudiness, not being as sharp, short-term memory being impaired, and slower processing speed are typical. Headaches would be more of a physical symptom, as well as oculomotor issues—like getting headaches when reading, or having really poor reading comprehension or slowed reading. Nausea would be another physical symptom.

Age Differences in Brain Injury & Plasticity

1:36

Stewart Cohen: Does that differ between children, teenagers, and adults—the kinds of things you look for?

Dr. Thomas Swirsky-Sachetti: Children are a whole different ballpark because a lot of the functions that we would measure, especially frontal lobe functions, wouldn’t even be in existence in their brains yet. The frontal lobes don’t fully develop until the early 20s. Limbic impulses shoot up, and they haven’t got enough frontal lobe to sit on top of it and direct it.

Generally speaking, the older you get, the harder it is to recover because your brain is more hardwired and less flexible. So older people have a harder time recovering fully from head injuries. Kids’ brains are remarkably flexible, so in one way, they’re good candidates for rehabilitation. But it depends on the age. If a child has a head injury before the age of five, that can have really deleterious consequences because so many functions haven’t even been developed yet—for instance, language pathways. In one of the cases we worked on involving a child under a year old who was injured in a car accident due to a faulty car seat, “deleterious” means not good. If those pathways can’t be established, recovery is very difficult.

On the positive side, for kids over the age of five, their brains are more flexible and resilient. They’re more able to hop over and use their right hemisphere when it’s typically a left hemisphere function. However, the degree of the injury will always have a major influence on the outcome.

Teenage years are an unusual period because a lot of basic functions have developed, but the frontal lobe hasn’t. One of the primary developmental tasks of adolescence is to bond with a peer group and move away from dependency on parents. A mild head injury can make a teenager more dependent on their parents, which works directly against that developmental task. That friction can create all kinds of psychological problems—depression, low self-esteem, and anxiety—which further affect brain recovery.

Personality Types & Premorbid Psychological Factors

5:04

Stewart Cohen: You promised earlier to talk a little bit about the relationship between the psychological component of recovery and the brain injury itself. Seems like we’re at that natural point.

Dr. Thomas Swirsky-Sachetti: Before I was a neuropsychologist, I was a clinical psychologist, so I am very interested in personality. Some of my early research was on the brain underpinnings of personality.

Premorbidly—someone’s personality before the accident—is crucial to understand. That’s why I argue against really quick computerized test batteries that don’t take this into account. For example, if someone before an accident is on the obsessive-compulsive side—say, a successful attorney who likes their T’s crossed, I’s dotted, and needs to be in control—a head injury is going to cause immense anxiety because their personality style is disrupted. They are no longer in control. Forgetting three items at the grocery store grates on their nerves because they are used to being exacting.

On the other hand, consider the same level of head injury in someone with a histrionic personality type—someone who is gregarious, lively, and the life of the party. That same level of brain injury might not impact them in the same way. What would impact them more is a word-retrieval problem where they can’t deliver a punchline or engage in rapid speech, which directly affects their self-esteem. Understanding who the person was before the injury through interviews with family and evaluating occupation is essential. Some of our personality tests specifically measure premorbid personality rather than post-injury symptoms.

Additionally, prior head injuries increase the likelihood of protracted symptoms. While a mild head injury from 20 years ago isn’t as concerning, sustained concussions within a week or two—as seen in sports—can cause severe long-term issues like dementia. Premorbid depression is also a negative prognostic indicator for recovery. After a head injury, unaddressed depression and anxiety actively hinder recovery, which is why family support and counseling are critical.

Importance of Family Support & Recovery Timelines

9:48

Stewart Cohen: Are those family groups important in your experience? There are studies showing that families who participate in rehab help patients do better. Why is that?

Dr. Thomas Swirsky-Sachetti: Absolutely. Out of all the variables that best predict recovery—IQ, age, intelligence, occupation level, income—family support is number one. By providing that support, they create an optimal environment for the brain to heal while minimizing depression, anxiety, and emotional stressors that interfere with recovery.

Stewart Cohen: How soon after a brain injury is it appropriate to test?

Dr. Thomas Swirsky-Sachetti: About a week to 10 days post-injury, because most people begin recovering from immediate symptoms by that point. That primary recovery period can extend out to three months. Studies of football players and returning veterans show that most mild head injuries recover by three months. However, the sooner you start exercising the brain through rehab, the better the outcome. Waiting a full three months to begin rehab risks lost opportunities.

Testing Methods Across Age Groups

12:04

Stewart Cohen: Do you use different testing methods and treatment recommendations for different age groups—children, teenagers, and adults?

Dr. Thomas Swirsky-Sachetti: Yes. For children, it’s a completely different battery. While core tests like the Wechsler Intelligence Scale cover similar domains—executive function, motor, sensory memory, language, and personality—we use child-modified tests.

In terms of recovery timelines, adults take longer. It depends on premorbid health, depression, family support, and cognitive reserve. As we age, we utilize cognitive reserve to counter normal aging effects, but a head injury speeds up the aging process in some ways. Adults are less likely to feel they have returned 100% to baseline. Kids over five are more likely to have a strong recovery due to brain adaptability, depending on the extent of the injury.

Flaws in Computerized Testing & Insurance Evaluations

16:08

Stewart Cohen: Earlier you mentioned concerns about quick, computer-generated testing. What are your thoughts on that?

Dr. Thomas Swirsky-Sachetti: Insurance companies push to make evaluations quicker and cheaper because a full day of neuropsychological testing is expensive. So they’ve developed one-hour computerized tests, like the ImPACT test. They often conduct group testing in high schools, putting 30 adolescents in a room to take the baseline test at the start of the year. With 30 kids in a classroom throwing spitballs and looking around unmonitored, the results are barely valid.

Beyond administration issues, the test validity is limited because it is entirely visual on a screen—it doesn’t measure auditory, tactile, or kinesthetic processing. Furthermore, athletes engage in “sandbagging”—intentionally bombing the baseline test so that if they get a concussion during the season, their post-concussion score looks normal and they aren’t withheld from play. Peyton Manning famously referenced this practice. Computerized tests provide no way to measure effort or validity.

When insurance companies use these short computerized tests to evaluate brain injuries, it creates a bias against finding an injury. A comprehensive neuropsychological evaluation uses finely calibrated measures across cognitive, emotional, and behavioral domains. Computerized testing is far less thorough and easily misses subtle deficits.

Adaptability of the Human Brain

19:53

Stewart Cohen: What gives you hope when working with patients recovering from brain injuries?

Dr. Thomas Swirsky-Sachetti: Over 40 years of practice, I am continually amazed at how resilient people are. Despite clear deficits affecting them and their families, people show incredible perseverance and a “can-do” attitude. Cognitively, the brain’s ability to adapt and rewire itself makes it a truly amazing piece of machinery.

Stewart Cohen: Thank you, doctor.

Dr. Thomas Swirsky-Sachetti: Thanks for having me. It was fun.