THE COGNITIVE EFFECTS OF HEAD INJURY
by Trevor Powell
Craig has been researching and studying in this field for nearly twenty years
stemming from a long-standing head injury. He hopes that by sharing that it
will make some difference in those lives affected by brain injury. Craig likes
to share knowledge and insights from his life experiences to try and help
others. He hopes that by sharing, it will make some difference in those lives
affected by brain injury.
Part of the text is reproduced by kind permission of Trevor Powell from his
book ‘Head Injury: A Practical Guide’.
The cognitive effects of a brain injury
affect the way a person thinks, learns and remembers. Different mental
abilities are located in different parts of the brain, so a head injury can
damage some, but not necessarily all, skills such as speed of thought, memory,
understanding, concentration, solving problems and using language.
The cognitive system can be divided up into
six separate areas:
Memory is not one thing or one skill on its
own. It is easily damaged by brain injury because there are several structures
within the brain which are involved in processing information, storing it and
retrieving it. Damage to those parts of the brain on which these abilities
depend can lead to poor memory. Problems with memory is a complex subject and
is covered in more depth in a separate section.
Headway has produced a publication Memory
Problems After Brain Injury that provides further information.
Attention and Concentration
A reduced concentration span is very common
after head injury, as is a reduced ability to pay attention to more than one
task at the same time. These problems are usually caused by damage to the
frontal lobe. Attentional problems tend to get worse when the person is tired,
stressed or worried. When there are problems with concentration, other skill
areas can be affected. It is difficult to follow instructions, plan ahead, be
organised and so on, when there is a problem concentrating. Working in a place
with as few distractions as possible can help and, as concentration improves,
distractions can be increased. In this way, someone can slowly learn to
concentrate better in a world which is crowded with distracting sights and
Speed of Information Processing
Slowing down the speed at which the brain
performs the task of information processing is often due to ‘diffuse axonal
damage’ caused by a shake up of all of the pathways the brain uses to transmit
messages. This results in problems such as not understanding fast speech, being
unable to absorb instructions first time around, and not being able to quickly
formulate a reply to a question. To improve the speed of information
processing, it is advisable to keep mentally stimulated at the right level to
Executive Functions – Planning, Organising,
Damage to the frontal lobe can affect these
skills, resulting in a subtle set of deficits which have been called
‘Dysexecutive Syndrome’. This covers problems in making long-term plans, goal setting and initiating
steps to achieve objectives. The ability to stand back and take an objective
view of a situation may be lacking, as may the ability to see anything from
another person’s point of view. If the person is aware that this is a problem,
then encouragement and direct feedback can be given to help the person modify
their behaviour. It is useful to try to create structure in otherwise
unstructured situations, by breaking down any task into specific tasks, perhaps
using checklists. Flexible thinking is made up of both divergent thinking
(thinking outwards or generating ideas from a single point) and convergent
thinking (thinking inwards, taking ideas and summarising them). Exercises which
practice these skills not only improve ability but help to identify
difficulties and improve awareness.
Visuo-Spatial and Perceptual Difficulties
Organs such as ears and eyes may be working
perfectly well, but the part of the brain which makes sense of incoming
information from these sources may not be working properly. This gives rise to
several different types of difficulty. Problems in judging distances, spatial
relationships and orientation can mean, for example, that a person may bump
into furniture that they have seen, but have misjudged where it is in relation
to themselves. Sometimes a person will have a problem where one side of
whatever they are looking at is not seen (visual neglect). A person may only
eat half the food on their plate, or read only halfway the across the page. The
ability to recognise something viewed from a different or unusual angle can be
lost. This can also apply to sounds as well as vision. Building objects or
drawing them from component parts such as coloured block may be very hard.
Problems with language loss can be either
receptive such that no sense can be made of what is heard or read, or
expressive which means it is not easy to find the right words to say or write.
Difficulties with these areas are known as aphasia. When both problems are
present the condition is known as ‘global aphasia’. There is a special area on
the left side of the brain concerned with producing speech (Broca’s area which
is located between the frontal and temporal lobes) and another area for
understanding the speech of others (Wernickes’s area which is located further
back between the temporal and parietal lobes). These two are connected by
numerous pathways but are quite distinct. It is useful to remember that the
brain skills which produce and understand speech are different to the ability
to make the sounds of language. The latter can be due to problems with the
muscles in the throat and mouth, and more detailed information is given in the
section on physical effects after head injury.
A publication titled Communication Problems
after Brain Injury is available which describes the common problems and gives
hints and tips on dealing with them.
Other organisations can help, such as
Everyone who has had a head injury can be
left with some changes in emotional reaction and behaviour. These are more
difficult to see than the more obvious problems such as those which affect
movement (a physical effect) and speech (a cognitive effect), for example, but
can be the most difficult for the individual concerned and their family to deal with.
Headway has produced publications to help
and advise on many of the problems outlined below. There are more than twenty
titles covering subjects such as Psychological Effects of Brain Injury and
Personal and Sexual Relationships Following Brain Injury
Headway’s network of local Groups and
Branches are an excellent source of advice and support for the head injured
person and members of the family
by people who have experienced these difficulties at first hand, and can advise
on coping strategies and treatment methods.
This subject is very large, and not
everybody will experience all of the problems below. The severity of the
problems will also vary.
Explosive Anger and Irritability
For example, exaggerated angry reaction to
apparently minor annoyances.
Direct damage to the frontal lobes, which
is the part of the brain which controls emotional behaviour and tolerance of
frustration, can create emotional lability. This means emotions can swing to
extremes. The stress of coping with even minor crises, such as misplaced shoes
or a noisy vacuum cleaner, can be too much and trigger an angry outburst. If
these stresses can be identified, they may be able to be reduced.
Lack of Awareness and Insight
The mental ability to monitor personal
behaviour and adjust it accordingly is a sophisticated skill contained in the
frontal lobes of the brain. Damage to this area affects the ability to be
self-aware, have insight into the effects of personal actions, show sensitivity
or feel empathy. It also means that a person may not fully appreciate or
understand the effect that the accident is having on their life, health or family. Involvement in a head
injury support group can be very useful for meeting people at various stages of
recovery, who can help a person recognise difficulties they may also be
Impulsivity and Disinhibition
For example, speaking your mind no matter
what the circumstances, touching people inappropriately, and not considering
the consequences of any action.
This is the lack of ability to control
either actions or speech, and is due to neurological damage to the frontal
lobes. This problem often goes hand in hand with lack of awareness, and the
person may not be aware of breaching any social rules or etiquette. A behavioural
management system devised with the help of a neuro-psychologist can help
improve the situation, and prevent a person developing unacceptable behaviour
This describes a person’s tendency to laugh
and cry very easily and to move from one emotional state to another very
Loss of control over emotions means the
person has lost the ability to discriminate about when and how to express their
feelings. This can be very tiring and embarrassing for family members to deal
with, but in time a person can begin to re-learn emotional control.
For example, not showing any interest in
family matters, and only being concerned with personal needs.
This can be partly due to direct brain
injury affecting a person’s ability to judge how another person is feeling, and
may be partly due to a person becoming accustomed to the huge amount of
attention focused on a head injury survivor while they were in hospital. The
result can be very hard to cope with. It needs to be handled firmly to avoid a
family feeling their effort and love are not appreciated.
Apathy and Poor Motivation
For example, no interest in hobbies enjoyed
previously, or not being bothered to get out of a chair all day.
Lack of motivation or spontaneity,
or apathy, is a direct result of brain injury to frontal lobe structures that
concern emotion, motivation
or forward planning. Over time, lack of motivation can lead to
social isolation and lack of pleasure. To help, activities can be broken down
into small steps to avoid overwhelming the person.
For example, feeling there is no point in
having survived the accident, or thinking that everything has changed for the
Depression is a very common
emotional reaction which comes on in the later stages of rehabilitation, often
when a person realises the full extent of the problems caused by the accident.
This can be seen as a good sign, that a person is aware of the reality of the
situation, and is coming to term with the emotional consequences. ‘Healthy’ depression can be worked
through in time, as adjustments are made. If a person feels emotionally blocked
and unable to move on, professional counselling from someone who understands
head injury may be helpful.
For example, panic attacks, nightmares, and
feelings of insecurity.
It is natural for people involved in a
traumatic experience to feel anxious afterwards. Loss of confidence when faced
with situations and tasks which are difficult to cope with is also a pretty
normal reaction. However, long standing problems can occur if difficult
situations are continually avoided, or if carers encourage dependence rather
than independence. Talking about fears and worries is very helpful, and
adopting methods of staying calm under stress can reduce the effect of anxiety on everyday life.
Inflexibility and Obsessionality
For example, unreasonable stubbornness,
obsessive pattern of behaviour such as washing or checking things, or fear of
possessions being stolen.
The ability to reason must not be taken for
granted. The roots of this type of rigid behaviour are in cognitive
difficulties resulting from damage to the frontal lobes. The person can lose
the ability to jump from one idea to another, and becomes ‘stuck’ on one
particular thought. This type of behaviour is often made worse by anxiety or insecurity, so
reassurance is helpful, as is trying to redirect attention to more constructive
ideas and behaviour. This type of behaviour can be very irritating to family
and friends, and often leads to social isolation.
Part of the text is reproduced by kind
permission of Trevor Powell from his book Head Injury: A Practical Guide
Fatigue after head injury can be one of the
most limiting symptoms because it affects everything a person does. Energy
stores are easily depleted, and it can take a long time to build up the
reserves again. By pushing themselves too hard a head injured person can
exhaust the supply of energy, so it is better to recognise the early signs of
fatigue and to rest.
Movement, Balance and Co-ordination
Damage to the brain which causes movement
difficulties usually happens to the motor cortex, the brain stem and the
cerebellum. As one side of the brain affects the motor co-ordination on the
opposite side of the body, a person often experiences a weakness or paralysis
of one side. Damage to the cerebellum affects fine co-ordination of the
muscles, and can mean continuing problems with dexterity even after a period of
improvement. Difficulties with balance can be caused by damage to the
vestibular system, which is a small mechanism at the back of the skull. Even a
minor brain injury can upset this delicate organ, so that the person often
feels dizzy. Learning to
walk again after a head injury involves re-learning the basic developmental
stages so that they learn to balance before a stable posture can be achieved.
Contractures, that is, abnormal shortening of muscles which make it very hard
to stretch limbs, can seriously affect posture. Exercises provided by the
physiotherapist are essential in helping to overcome this in the early stages.
More severe contractures may require the muscle to be encased in plaster and
Dyspraxia is a disorder of deliberate
voluntary actions, or sequences of actions. That means it is different from
problems with motor co-ordination or movement. The person may not have a
problem with actual movement, rather the problem lies with being unable to put
movements together deliberately and intentionally. This kind of problem can
often be perceived as a lack of co-operation on the person’s part. A good
example of the kind of problem would be a person who cannot bend his elbow when
instructed to, but a few minutes later could tell the time by looking at his
watch which involves bending his elbow quite automatically. Rehabilitation aims
to break actions down into a sequence of activities, with cues and prompts,
which is then practised until the cues and prompts can be gradually dispensed
Loss of Sensation
Different parts of the sensory cortex deal
with sensations in different parts of the body. After a head injury, people may
experience a loss of sight, hearing, taste, smell (anosmia) and so on without
actually damaging any of the sense organs. If the sensory cortex has been
bruised, a gradual recovery of sensation may be possible. If the area has been
torn, it is unlikely to return to normal functioning. Processing what the eyes
see is carried out in the occipital lobes at the back of the brain. Damage here
can result in either full or partial blindness, or gaps in the visual field.
Visual neglect is covered in the section on cognitive problems. Temperature
control can also be affected, particularly by damage to the brain stem.
Reproduced from the Headway web site: http://www.headway.org.uk
© Headway – the brain injury association Reg Charity No 1025852
“Success to others may be apparent in
what you DO; but
significance, meaning and purpose lies, then reveals itself
in what you ARE and BECOME down the ‘river of life’ – how
and the spirit with which you face, then overcome the daily
obstacles, the frequent trials and tribulations along the
often rocky path-way of life’s magical and mysterious
Light your path brightly.”‘
P.S: To end off, enjoy these thoughts…
“We have it within; but we get it all
from without. There is a well-spring
of strength, wisdom,
courage and great imagination
within each one of us; but once we draw on this truth, it gets watered from
without, by a Higher Source – the Source of Life and Love, which is God, the
very Ground of our Being.”
“When you can see no light at the end
of the tunnel, light your own candle and let your light illuminate the world,
like the radiance from a window at midnight.”
That’s a metaphor, BTW
“When the world is filled with love,
peoples hearts are overflowing
“The task ahead of you can always be
overcome by the power within you…and the seemingly difficult path ahead of
you is never as steep with the great spirit that lies within you.”
Part of the text is reproduced by kind permission of
Trevor Powell from his book ‘Head Injury: A Practical Guide’.
“With knowledge comes