Exploring the link between mental disorder, traumatic brain injury
John Hricak recalled one morning when he looked in the mirror and noticed how much he had changed.
"I remember thinking, 'Gosh, John, you've lost weight,'" said Hricak of Grand Forks.
It was the first memory he had in the months following the February 2005 traffic accident when his truck was hit by a semi on I-29 near the exit to Thompson, N.D. The accident put him in the hospital and on a long path to recovery.
"I weighed 147 pounds," he said. "I weighed 193 the day before the accident."
The brain injury he sustained in that accident erased part of his memory.
"I don't remember the accident or rehab," he said. "I don't remember anything."
He learned from others what had happened to him, including the fact that just after the accident a nurse told his daughter-in-law not to leave the hospital because he was not expected to live.
He was in a coma, tethered to breathing and feeding tubes. Doctors drained excess fluid from his brain to relieve pressure. He lost the use of his left eye and ear.
About 5,000 Americans suffer a traumatic brain injury every year, according to the Centers for Disease Control and Prevention. A total of 13,000 North Dakotans are dealing with the consequences of TBI, some of which, research shows, include the risk of developing mental disorders such as depression, schizophrenia and bipolar disorder.
Hricak returned to his job with the U.S. Border Patrol in Grand Forks in June 2005.
In the years following the accident, he's had repeated memory lapses.
For example, he spent three days helping build a fence at his son's home and took a trip to visit relatives out of state, but has no recollection of either event.
He keeps track of appointments in a calendar.
"Sometimes it is frustrating," he said, but the challenges that other TBI survivors face put things into perspective.
Asked whether he has suffered any mental disorders, such as depression, in the years since the accident, Hricak said, "I'm sure I did. How could you not? If you lose an eye and an ear, it's going to affect you."
"I don't know a person who doesn't have a mental challenge, one way or another," he said.
He takes a prescription medication to stabilize his moods.
Researchers say that trauma to the head can significantly increase one's risk of developing certain mental disorders such as schizophrenia, depression and bipolar disorder — in some cases by more than 400 percent.
Danish scientist Dr. Sonja Orlovska, of the Psychiatric Centre Copenhagen, said although she expected to see a correlation between head injury and the subsequent risk of mental illness, she was "quite surprised" by findings of a study she led.
The correlation "was stronger than I expected," she said in a ScienceNordic.com article in January 2014.
In the largest study of its kind, researchers followed a pool of Danes who had been admitted to the hospital with a head injury.
Orlovska and her colleagues looked for diagnoses of depression, schizophrenia, bipolar disorder and "organic mental disorders," a form of decreased mental function due to a medical or physical disease, rather than a psychiatric illness.
Comparing the injured people's risk of developing disorders with the rest of the population, they found that those with head injuries were:
• 65 percent more likely to be diagnosed with schizophrenia.
• 59 percent more likely to develop a depression.
• 28 percent more likely to be diagnosed with bipolar disorder.
• 439 percent more likely to suffer from organic mental disorders.
The greatest risk of developing a mental disorder is in the first year after suffering head trauma, they reported, but even after 15 years there was a significantly increased risk.
Head injury between the ages of 11 and 15 was the strongest predictor for subsequent development of schizophrenia, depression and bipolar disorder.
"There is a significant overlap between those who have mental health disorders and TBI, but we don't know causality," said Rebecca Quinn, who works with the North Dakota Brain Injury Network as program director with the Center for Rural Health at UND.
Trauma to the brain "is so difficult to work with," Quinn said. "We don't have a complete understanding of how the brain works."
Certain mental disorders are thought to be caused by a chemical imbalance in the brain, so damage to brain structures that carry those chemicals could play a part in the development of mental disorders.
"We don't have a grasp on that," she said. "You can have trauma that's psychological, physical, genetic or (related to toxin) exposure. We don't know how they interconnect."
In her work with people who've suffered TBI, she said, "I have brain-injured individuals who don't go on to develop mental health disorders and those who do. We don't have enough knowledge to rule anything out."
Although there is no definite explanation to the correlation between head injuries and the subsequent development of mental disorders, Orlovska and her colleagues point to possible explanations such as trauma-induced inflammation and disruption in the balance of chemicals the brain uses to communicate between various parts of the nervous system.
Head injuries that occur in connection with a traumatic accident may produce a psychological and emotional reaction that triggers the mental disorder, experts say. The loss of bodily functions or abilities after an accident with head trauma may also affect the psyche so that the person develops a mental disorder.
TBI affects thousands
"About 13,000 North Dakotans are living with consequences of TBI, including injuries resulting from sports, falls and motor vehicles crashes," Quinn said.
"Falls are the most common injury that causes TBI across the board," she said. "Vehicle crashes are the cause of more severe injury."
Slips on ice, childhood falls on the playground, and falls among construction and oil industry workers are examples of accidents that can result in significant injury, she said. "You don't realize how something little can lead to something worse," she said.
Injury to the brain is much different from injury to other parts of the body, Quinn said.
An injury such as a broken limb or punctured lung limits the use of that specific part, but body structures heal and regain their previous function.
"The brain controls everything we do, so a brain injury can impact everything we do," she said.
Consequences of a brain injury can affect all aspects of one's life, including personality, according to TraumaticBrainInjury.com.
Quinn said she's never experienced a time when presenting on brain injuries that someone doesn't come up afterward to share their experience. She said so many people have been impacted and never really know if a past head trauma may have been a factor.
"Some will say (of their child's behavior), 'I thought it was a typical teenage issue, but now we're wondering ...,'" she said.
Brain injuries do not heal like other injuries, according to TraumaticBrainInjury.com. No two brain injuries are alike and the consequences of two similar injuries may be very different. Symptoms may appear right away or may not be present for days or weeks after the injury.
"Some symptoms — like dizziness, loss of concentration, confusion, slurred speech or vision disturbances — can resolve themselves," she said. But later symptoms such as migraine headaches, memory problems and sleep disturbances can occur.
"The brain is so mysterious it's difficult to predict how much they will recover over time," she said. "Some are told they'd never walk again, and now they're walking."
North Dakota has taken steps to learn more about how brain injuries affect its citizens, Quinn said.
In 2011, the state human services department launched a screening program that found 30 percent of individuals who access substance abuse and mental health services have a history of TBI, she said. That's pretty consistent with other studies conducted across the country, she added.
Studies of prison inmates in Minnesota and elsewhere "have put their history of TBI above about 60 or 70 percent," she said, "which leads researchers to ask 'why do so many people with TBI end up in prison?'"
Minnesota has a higher recidivism, or rate of repeat criminal behavior, among those affected by TBI, she said. It is considering possible ways to rehabilitate prisoners before they leave prison to reduce their chances of returning.
TBI affects skills such as decision-making ability, memory (to remember outcomes of prior actions), impulse control and the ability to weigh consequences.
TBI is "significantly higher" among the homeless and substance-abuse populations, she said. "The skill set required to stay out of these populations isn't there," she said.
Hricak, who took disability retirement in 2008 at age 57, is active in the local TBI support group that meets monthly at Sharon Lutheran Church in Grand Forks.
The group, which is affiliated with the North Dakota Brain Injury Network, draws people who range in age from 11 to 68.
"We have hard times remembering, we have hard times understanding," he said. "We have emotional issues that are not under control — like 'normal' people.
"We have periods of depression like everyone else. It may be worse than others, but it's not necessarily always that way."
The goal of the support group is "to have a place where they can be themselves," he said.
"Like everybody else, we have good days and bad days. (People with TBI) may not be able to do things that others think they should."
Asked if he ever questioned why he was the victim of such a traumatic accident, he said, "Maybe at first. But it is what it is. I can't change it, so I really don't worry about it."