psychology case study brain damage

“Considering everything, it seems we are dealing here with a special illness… There are certainly more psychiatric illnesses than are listed in our textbooks.” —Alois Alzheimer (In: Benjamin, 2018)

Once thought to be the product of demonic possession, immorality, or imbalanced humors, we now know that psychiatric symptoms are often caused by changes in the brain. Read on to learn about the people who helped us understand the brain as the driving force behind our behaviors.

Phineas Gage

In 1848, John Harlow first described the case of a 25-year-old railroad foreman named Phineas Gage. Gage was a "temperate" man: hardworking, polite, and well-liked by all those around him. One day, Gage was struck through the skull by an iron rod launched in an accidental explosion. The rod traveled through the prefrontal cortex of his brain. Remarkably, he survived with no deficits in his motor function or memory . However, his family and friends noticed major changes in his personality . He became impatient, unreliable, vulgar, and was even described as developing the "animal passions of a strong man." This was the first glimpse into the important role of the prefrontal cortex in personality and social behavior (David, 2009; Thiebaut de Schotten, 2015; Benjamin, 2018).

Louis Victor Leborgne

Pierre Broca first published the case of 50-year-old Louis Victor Leborgne in 1861. Despite normal intelligence , Leborgne inexplicably lost the ability to speak. His nickname was Tan, after this became the only word he ever uttered. He was otherwise unaffected and seemed to follow directions and understand others without difficulty. After he died, Broca examined his brain, finding an abnormal area of brain tissue only in the left anterior frontal lobe. This suggested that the left and right sides of the brain were not always symmetric in their functions, as previously thought. Broca later went on to describe several other similar cases, cementing the role of the left anterior frontal lobe (now called Broca’s area) as a crucial region for producing (but not understanding) language (Dronkers, 2007; David, 2009; Thiebaut de Schotten, 2015).

Auguste Deter

Psychiatrist and neuropathologist Aloysius Alzheimer described the case of Auguste Deter, a 56-year-old woman who passed away in 1906 after she developed strange behaviors, hallucinations, and memory loss. When Alzheimer looked at her brain under the microscope, he described amyloid plaques and neurofibrillary tangles that we now know are a hallmark of the disease that bears his name. This significant discovery was the first time that a biological molecule such as a protein was linked to a psychiatric illness (Shorter, 1997; David, 2009; Kalia & Costa e Silva, 2015).

In 1933, Spafford Ackerly described the case of "JP” who, beginning at a very young age, would do crude things like defecate on others' belongings, expose himself, and masturbate in front of other children at school. These behaviors worsened as he aged, leading to his arrest as a teenager . He was examined by Ackerly who found that the boy had a large cyst, likely present from birth, that caused severe damage to his prefrontal cortices. Like the case of Phineas Gage, JP helped us understand the crucial role that the prefrontal cortex plays in judgment, decision-making , social behaviors, and personality (Benjamin, 2018).

HM (Henry Gustav Molaison)

William Scoville first described the case of HM, a 29-year-old man whom he had treated two years earlier with an experimental surgery to remove his medial temporal lobes (including the hippocampus and amygdala on both sides). The hope was that the surgery would control his severe epilepsy, and it did seem to help. But with that improvement came a very unexpected side effect: HM completely lost the ability to form certain kinds of new memories. While he was still able to form new implicit or procedural memories (like tying shoes or playing the piano), he was no longer able to form new semantic or declarative memories (like someone’s name or major life events). This taught us that memories were localized to a specific brain region, not distributed throughout the whole brain as previously thought (David, 2009; Thiebaut de Schotten, 2015; Benjamin, 2018).

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Benjamin, S., MacGillivray, L., Schildkrout, B., Cohen-Oram, A., Lauterbach, M.D., & Levin, L.L. (2018). Six landmark case reports essential for neuropsychiatric literacy. J Neuropsychiatry Clin Neurosci, 30 , 279-290.

Shorter, E., (1997). A history of psychiatry: From the era of the asylum to the age of Prozac. New York: John Wiley & Sons, Inc.

Thiebaut de Schotten, M., Dell'Acqua, F., Ratiu, P. Leslie, A., Howells, H., Cabanis, E., Iba-Zizen, M.T., Plaisant, O., Simmons, A, Dronkers, N.F., Corkin, S., & Catani, M. (2015). From Phineas Gage and Monsieur Leborgne to H.M.: Revisiting disconnection syndromes. Cerebral Cortex, 25 , 4812-4827.

David, A.S., Fleminger, S., Kopelman, M.D., Lovestone, S., & Mellers, J. (2009). Lishman's organic psychiatry: A textbook of neuropsychiatry. Hoboken, NJ: Wiley-Blackwell.

Kalia, M., & Costa e Silva, J. (2015). Biomarkers of psychiatric diseases: Current status and future prospects. Metabolism, 64, S11-S15.

Dronkers, N.F., Plaisant, O., Iba-Zizen, M.T., & Cabanis, E.A. (2007). Paul Broca's historic cases: High resolution MR Imaging of the brains of Leborgne and Lelong. Brain , 130, 1432–1441.

Scoville, W.B., & Milner, B. (1957). Loss of recent memory after bilateral hippocampal lesions. J. Neurol. Neurosurg. Psychiat., 20, 11-21.

Melissa Shepard, MD , is an assistant professor of psychiatry at the Johns Hopkins School of Medicine.

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Brain Stuff

Famous case studies in neuroscience and psychology, acquired savant syndrome.

Patient HM (Henry Molaison) : Man who experienced anterograde amnesia and partial retrograde amnesia after a bilateral temporal lobectomy to cure his epilepsy.

Patient RB: Man who experienced a stroke that damaged the CA1 region of his hippocampus. As a result, he lost his ability to form new memories.

Clive Wearing: British man with a severe anterograde and retrograde amnesia. He has lost most of his declarative memory, but his implicit memory is still in tact.

Anti-NMDA Receptor Encephalitis

Susannah Cahalan : Woman who had developed an unusual set of symptoms that included a rapid onset psychosis. Her autobiography, Brain on Fire , is a first hand narrative of this condition. Her story has also been turned into a movie.

Patient Tan (Victor Louis Leborgne) : Man who had severe expressive aphasia after syphilis damaged his left frontal lobe. He was examined by Dr. Paul Broca, who conducted the autopsy on Tan’s brain and discovered a large lesion. His specific form of aphasia was later called Broca’s aphasia.

Lazare Lelong : A patient of Dr. Paul Broca with expressive aphasia. Post mortem examination showed injury to the same area of the brain as seen in other case studies of a similar type of aphasia.

Jebediah Buxton: Man with savant skills for mathematical calculations.

Brain Injury

Phineas Gage: Man who survived after a large metal rod was sent flying through his skull and brain. Following the injury, he had a marked change in behavior that was uncharacteristic of him before the injury.

Jill Bolte Taylor: Neuroscientist who experienced a rupture of an arteriovenous malformation , resulting in severe bleeding in the left hemisphere of her brain. Her autobiography, My Stroke of Insight, details her experiences from having the stroke to rehabilitation. She has also given a TED talk about her stroke.

Parkinson's Disease

"The Frozen Addicts" : Group of six people in California who mistakenly took a toxin called MPTP. After exposure, the patients developed bradykinesia (slowness of movement) and tremors, which resembles the symptoms of Parkinson's disease.

Urbach-Wiethe Disease

Patient SM : Person with severe amygdala damage as a result of highly specific calcification. Because of this damage, she exhibited no fear on behavioral testing.

Psychology’s 10 Greatest Case Studies – Digested

These ten characters have all had a huge influence on psychology and their stories continue to intrigue each new generation of students.

27 November 2015

By Christian Jarrett

These ten characters have all had a huge influence on psychology and their stories continue to intrigue each new generation of students. What’s particularly fascinating is that many of their stories continue to evolve – new evidence comes to light, or new technologies are brought to bear, changing how the cases are interpreted and understood. What many of these 10 also have in common is that they speak to some of the perennial debates in psychology, about personality and identity, nature and nurture, and the links between mind and body.

Phineas Gage

One day in 1848 in Central Vermont, Phineas Gage was tamping explosives into the ground to prepare the way for a new railway line when he had a terrible accident. The detonation went off prematurely, and his tamping iron shot into his face, through his brain, and out the top of his head. Remarkably Gage survived, although his friends and family reportedly felt he was changed so profoundly (becoming listless and aggressive) that “he was no longer Gage.” There the story used to rest – a classic example of frontal brain damage affecting personality. However, recent years have seen a drastic reevaluation of Gage’s story in light of new evidence. It’s now believed that he underwent significant rehabilitation and in fact began work as a horse carriage driver in Chile. A simulation of his injuries suggested much of his right frontal cortex was likely spared, and photographic evidence has been unearthed showing a post-accident dapper Gage. Not that you’ll find this revised account in many psychology textbooks: a recent analysis showed that few of them have kept up to date with the new evidence. H.M.

Henry Gustav Molaison (known for years as H.M. in the literature to protect his privacy), who died in 2008, developed severe amnesia at age 27 after undergoing brain surgery as a form of treatment for the epilepsy he’d suffered since childhood. He was subsequently the focus of study by over 100 psychologists and neuroscientists and he’s been mentioned in over 12,000 journal articles! Molaison’s surgery involved the removal of large parts of the hippocampus on both sides of his brain and the result was that he was almost entirely unable to store any new information in long-term memory (there were some exceptions – for example, after 1963 he was aware that a US president had been assassinated in Dallas). The extremity of Molaison’s deficits was a surprise to experts of the day because many of them believed that memory was distributed throughout the cerebral cortex. Today, Molaison’s legacy lives on: his brain was carefully sliced and preserved and turned into a 3D digital atlas and his life story is reportedly due to be turned into a feature film based on the book researcher Suzanne Corkin wrote about him: Permanent Present Tense, The Man With No Memory and What He Taught The World .

Victor Leborgne (nickname “Tan”)

The fact that, in most people, language function is served predominantly by the left frontal cortex has today almost become common knowledge, at least among psych students. However, back in the early nineteenth century, the consensus view was that language function (like memory, see entry for H.M.) was distributed through the brain. An nineteenth century patient who helped change that was Victor Leborgne, a Frenchman who was nicknamed “Tan” because that was the only sound he could utter (besides the expletive phrase “sacre nom de Dieu”). In 1861, aged 51, Leborgne was referred to the renowned neurologist Paul Broca, but died soon after. Broca examined Leborgne’s brain and noticed a lesion in his left frontal lobe – a segment of tissue now known as Broca’s area. Given Leborgne’s impaired speech but intact comprehension, Broca concluded that this area of the brain was responsible for speech production and he set about persuading his peers of this fact – now recognised as a key moment in psychology’s history. For decades little was known about Leborgne, besides his important contribution to science. However, in a paper published in 2013, Cezary Domanski at Maria Curie-Sklodowska University in Poland uncovered new biographical details, including the possibility that Leborgne muttered the word “Tan” because his birthplace of Moret, home to several tanneries.

Wild Boy of Aveyron

The “Wild boy of Aveyron” – named Victor by the physician Jean-Marc Itard – was found emerging from Aveyron forest in South West France in 1800, aged 11 or 12, where’s it’s thought he had been living in the wild for several years. For psychologists and philosophers, Victor became a kind of “natural experiment” into the question of nature and nurture. How would he be affected by the lack of human input early in his life? Those who hoped Victor would support the notion of the “noble savage” uncorrupted by modern civilisation were largely disappointed: the boy was dirty and dishevelled, defecated where he stood and apparently motivated largely by hunger. Victor acquired celebrity status after he was transported to Paris and Itard began a mission to teach and socialise the “feral child”. This programme met with mixed success: Victor never learned to speak fluently, but he dressed, learned civil toilet habits, could write a few letters and acquired some very basic language comprehension. Autism expert Uta Frith believes Victor may have been abandoned because he was autistic, but she acknowledges we will never know the truth of his background. Victor’s story inspired the 2004 novel The Wild Boy and was dramatised in the 1970 French film The Wild Child .

Nicknamed ‘Kim-puter’ by his friends, Peek who died in 2010 aged 58, was the inspiration for Dustin Hoffman’s autistic savant character in the multi-Oscar-winning film Rain Man . Before that movie, which was released in 1988, few people had heard of autism, so Peek via the film can be credited with helping to raise the profile of the condition. Arguably though, the film also helped spread the popular misconception that giftedness is a hallmark of autism (in one notable scene, Hoffman’s character deduces in an instant the precise number of cocktail sticks – 246 – that a waitress drops on the floor). Peek himself was actually a non-autistic savant, born with brain abnormalities including a malformed cerebellum and an absent corpus callosum (the massive bundle of tissue that usually connects the two hemispheres). His savant skills were astonishing and included calendar calculation, as well as an encyclopaedic knowledge of history, literature, classical music, US zip codes and travel routes. It was estimated that he read more than 12,000 books in his life time, all of them committed to flawless memory. Although outgoing and sociable, Peek had coordination problems and struggled with abstract or conceptual thinking.

“Anna O.” is the pseudonym for Bertha Pappenheim, a pioneering German Jewish feminist and social worker who died in 1936 aged 77. As Anna O. she is known as one of the first ever patients to undergo psychoanalysis and her case inspired much of Freud’s thinking on mental illness. Pappenheim first came to the attention of another psychoanalyst, Joseph Breuer, in 1880 when he was called to her house in Vienna where she was lying in bed, almost entirely paralysed. Her other symptoms include hallucinations, personality changes and rambling speech, but doctors could find no physical cause. For 18 months, Breuer visited her almost daily and talked to her about her thoughts and feelings, including her grief for her father, and the more she talked, the more her symptoms seemed to fade – this was apparently one of the first ever instances of psychoanalysis or “the talking cure”, although the degree of Breuer’s success has been disputed and some historians allege that Pappenheim did have an organic illness, such as epilepsy. Although Freud never met Pappenheim, he wrote about her case, including the notion that she had a hysterical pregnancy, although this too is disputed. The latter part of Pappenheim’s life in Germany post 1888 is as remarkable as her time as Anna O. She became a prolific writer and social pioneer, including authoring stories, plays, and translating seminal texts, and she founded social clubs for Jewish women, worked in orphanages and founded the German Federation of Jewish Women.

Kitty Genovese

Sadly, it is not really Kitty Genovese the person who has become one of psychology’s classic case studies, but rather the terrible fate that befell her. In 1964 in New York, Genovese was returning home from her job as a bar maid when she was attacked and eventually murdered by Winston Mosely. What made this tragedy so influential to psychology was that it inspired research into what became known as the Bystander Phenomenon – the now well-established finding that our sense of individual responsibility is diluted by the presence of other people. According to folklore, 38 people watched Genovese’s demise yet not one of them did anything to help, apparently a terrible real life instance of the Bystander Effect. However, the story doesn’t end there because historians have since established the reality was much more complicated – at least two people did try to summon help, and actually there was only one witness the second and fatal attack. While the main principle of the Bystander Effect has stood the test of time, modern psychology’s understanding of the way it works has become a lot more nuanced. For example, there’s evidence that in some situations people are more likely to act when they’re part of a larger group, such as when they and the other group members all belong to the same social category (such as all being women) as the victim.

Little Albert

“Little Albert” was the nickname that the pioneering behaviourist psychologist John Watson gave to an 11-month-old baby, in whom, with his colleague and future wife Rosalind Rayner, he deliberately attempted to instill certain fears through a process of conditioning. The research, which was of dubious scientific quality, was conducted in 1920 and has become notorious for being so unethical (such a procedure would never be given approval in modern university settings). Interest in Little Albert has reignited in recent years as an academic quarrel has erupted over his true identity. A group led by Hall Beck at Appalachian University announced in 2011 that they thought Little Albert was actually Douglas Merritte, the son of a wet nurse at John Hopkins University where Watson and Rayner were based. According to this sad account, Little Albert was neurologically impaired, compounding the unethical nature of the Watson/Rayner research, and he died aged six of hydrocephalus (fluid on the brain). However, this account was challenged by a different group of scholars led by Russell Powell at MacEwan University in 2014. They established that Little Albert was more likely William A Barger (recorded in his medical file as Albert Barger), the son of a different wet nurse. Earlier this year, textbook writer Richard Griggs weighed up all the evidence and concluded that the Barger story is the more credible, which would mean that Little Albert in fact died 2007 aged 87.

Chris Sizemore

Chris Costner Sizemore is one of the most famous patients to be given the controversial diagnosis of multiple personality disorder, known today as dissociative identity disorder. Sizemore’s alter egos apparently included Eve White, Eve Black, Jane and many others. By some accounts, Sizemore expressed these personalities as a coping mechanism in the face of traumas she experienced in childhood, including seeing her mother badly injured and a man sawn in half at a lumber mill. In recent years, Sizemore has described how her alter egos have been combined into one united personality for many decades, but she still sees different aspects of her past as belonging to her different personalities. For example, she has stated that her husband was married to Eve White (not her), and that Eve White is the mother of her first daughter. Her story was turned into a movie in 1957 called The Three Faces of Eve (based on a book of the same name written by her psychiatrists). Joanne Woodward won the best actress Oscar for portraying Sizemore and her various personalities in this film. Sizemore published her autobiography in 1977 called I’m Eve . In 2009, she appeared on the BBC’s Hard Talk interview show.

David Reimer

One of the most famous patients in psychology, Reimer lost his penis in a botched circumcision operation when he was just 8 months old. His parents were subsequently advised by psychologist John Money to raise Reimer as a girl, “Brenda”, and for him to undergo further surgery and hormone treatment to assist his gender reassignment. Money initially described the experiment (no one had tried anything like this before) as a huge success that appeared to support his belief in the important role of socialisation, rather than innate factors, in children’s gender identity. In fact, the reassignment was seriously problematic and Reimer’s boyishness was never far beneath the surface. When he was aged 14, Reimer was told the truth about his past and set about reversing the gender reassignment process to become male again. He later campaigned against other children with genital injuries being gender reassigned in the way that he had been. His story was turned into the book As Nature Made Him, The Boy Who Was Raised As A Girl by John Colapinto, and he is the subject of two BBC Horizon documentaries. Tragically, Reimer took his own life in 2004, aged just 38.

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Case Study: Traumatic Brain Injury in an Elderly Woman

Abstract [ edit | edit source ]

The following fictional case study discusses possible interventions for restoring physical and cognitive function during an in-patient rehabilitation program of a 65-year old woman who presented with a traumatic brain injury (TBI) . She underwent surgical procedure to correct a subdural haematoma in the frontal lobe, resulting from a TBI. She entered the in-patient rehabilitation program two weeks after a craniotomy, with stable vitals. The initial examination findings included impaired memory, balance issues, limited ambulation and increased tone in the left upper and lower extremities as well as right upper extremities. Physiotherapy interventions consisted of balance training, task-specific exercises, strength training, flexibility exercises, gait training and postural education. Outcome measures were then used to reassess the patient's progress at week 4 of in-patient rehabilitation, including: the Berg balance scale, Ranchos Los Amigos scale, Modified Ashworth Scale, gait speed and distance measurements. The Functional Independence Measure (FIM) score improved from 68 upon rehabilitation to 106 when she was discharged to a home-rehabilitation program.

Introduction [ edit | edit source ]

Traumatic brain injury (TBI)s a major health condition [1] , and one of the common causes is falls [2] [3] . More specifically, subdural haematomas have been identified as one of the most prevalent injuries in patients who presented to the emergency department due to a TBI [3] . Few studies have looked at the role of rehabilitation and its effects on the improvement of functional outcomes in patients who have undergone surgery for subdural haematomas [4] . The purpose of this fictional case study is to explore the rehabilitation of an elderly woman with an acute TBI, post-surgical intervention.

Client Characteristics [ edit | edit source ]

A 65-year-old woman was getting groceries with her friend when she slipped on ice, hit her head and lost consciousness. An ambulance was called, and she was rushed to the hospital. The patient lost consciousness for one hour and remained in an altered state of consciousness for 24 hours. Diagnostic imaging confirmed right-sided focal subdural haematoma. Her Glasgow Coma Score (GCS) score upon arrival was 9 (E5; M2; V2) and she presented as a level III on the Ranchos Los Amigos Scale . The severity of her TBI was classified as ‘moderate’.

The patient underwent a craniotomy the following afternoon. After 2 weeks in the ICU, the patient’s Functional Independent Measure (FIM) score improved from 57 to 68 and was deemed appropriate for the in-patient rehabilitation unit. The patient presented with 7 days of retrograde amnesia , and no signs of anterograde amnesia. Her pre-existing conditions included hypertension and osteoporosis , and the medications she was taking for these conditions included Perindopril (Coversyl) and Alendronate (Fosamax), respectively. She had limited range of motion and required assistance with ambulation. Due to her FIM score, hospital protocol dictated that she was to enter an in-patient rehabilitation which includes daily physiotherapy.

Examination Findings [ edit | edit source ]

2 weeks post-op: in-patient rehabilitation program [ edit | edit source ], subjective [ edit | edit source ].

During the examination, information was collected from the patient’s chart, from members within the multidisciplinary team , the patient and her husband. As mentioned, diagnostic imaging confirmed right-sided focal subdural haematoma, affecting the frontal lobe. When speaking with the patient, she had complaints of dizziness and a headache earlier that morning. Prior to her fall, she was living with her husband in a bungalow and was independent in all activities of daily living . She is a retired teacher, and her husband is a healthy 68-year-old retired farmer. Her husband reported that she was active and independent and did not use any walking aids prior to her fall. She enjoyed activities such as pickleball, camping, hiking, baking and playing with her grandchildren. Her husband also stated that they had 4 steps to get into their house, with a railing on the right side. Her main goal was to return home and resume her regular activities. Upon gathering a subjective interview, her husband also explained that he was very concerned about his wife and that he was having difficulties coping with her changes in behaviour.

Objective [ edit | edit source ]

After the patient was admitted to in-patient rehabilitation, the patient’s screening results showed stable vital signs with a heart rate of 76bmp, blood pressure of 115/76, SpO2 of 97% and intact integuments. The physiotherapist proceeded to choose various outcome measures to obtain the patient’s mental status at baseline and monitor any changes over time.

The Galvestron Orientation and Amnesia Test (GOAT) was used to evaluate the patient’s orientation and ability to recall events before and after the incident [5] . Her GOAT score was 60/100, which was below the cut-off of 66, suggesting impaired memory [5] . Specifically, the patient had in-depth current memory and remembered most events after she gained consciousness in the ICU; however, she showed signs of retrograde amnesia from events that happened within 7 days prior to the incident [5] .

The Ranchos Los Amigos scale is a useful tool to rate the patient’s cognitive level after the patient regains consciousness from a TBI [6] . During initial assessment, she presented with level VI (Confused-appropriate) on the Ranchos Los Amigos scale [6] . As such, the patient was ready for rehabilitation since she was able to consistently follow simple directions (i.e., one step commands), showed carry over for relearned familiar tasks (e.g., self-care), and could attend to highly familiar tasks for a certain period of time [6] . However, the physiotherapist kept in mind that the patient required maximal assistance in learning new tasks due to the lack of carryover from previous sessions [6] . Additionally, the physiotherapist ensured to take proper safety measures (i.e., maximal supervision) since the patient was unaware of her impairments and was inconsistently oriented to person, time, and space [6] .

The Moss Attention Rating Scale (MARS) measures the effects of impaired attention on cognitive and motor performance specific to patients with TBI in acute rehabilitation [7] . Considering that patients at Rachos level VI mostly benefit from learning tasks in a non-distracting environment, the physiotherapist used MARS, an observational rating scale, to assess the patient’s daily attentional state and used the results to provide appropriate cueing to help the patient focus [7] .

Total Raw Score: 62/110

The Agitated Behavior Scale (ABS) was chosen to objectively measure the extent of agitation including levels of: disinhibition, aggression and liability, and is specific to the acute phase of acquired brain injury [9] . The patient scored 20/56 upon initial assessment, which is considered borderline normal [9] . Although patients at Ranchos level VI tend to have decreased agitated behaviour, the ABS was administered to monitor the extent of decrease over time [9] .

The Neurobehavioral Functioning Inventory Depression Scale (NFI) is used to measure post-injury depressive symptoms such as frustration, restlessness, loneliness, etc [10] . Research shows that the NFI Depression Scale is highly reliable and valid, and is sufficient at identifying minimal, borderline and clinical depression in patients with a TBI [10] . The patient scored 26/65 on the NFI Depression Scale. This score classified her as 'minimally depressed', which means that the patient rarely experiences depressive symptoms, therefore immediate intervention was not required, however signs of depressive symptoms were monitored throughout treatment [10] .

Clinical Impression [ edit | edit source ]

Physiotherapy diagnosis [ edit | edit source ].

Patient presented with a moderate TBI with imaging confirming an acute subdural haematoma affecting the frontal lobe of the brain . The patient demonstrated signs of increased tone, limited ROM, general weakness, and cognitive and behavioural deficits, such as, memory problems and mild agitation. Activities, such as walking, sitting, ascending/descending stairs, and moving limbs in isolation were affected. The patient was unable to resume regular activities such as pickleball, camping, hiking, baking, and playing with her grandchildren. However, she hoped to restore as much function as possible during rehabilitation so she could go back to doing things she enjoys. Patient was determined to be a good candidate for physiotherapy to help regain balance control, improve joint range of motion , reduce spasticity and overall restore physical function.

Problem List [ edit | edit source ]

Intervention [ edit | edit source ]

The patient was at Ranchos level VI (confused-appropriate), and was not cognitively aware of her condition, therefore the focus of her in-patient rehabilitation was to create a program based on not only the patient's goals, but also the facility's protocol on TBI rehabilitation. The treatment included restoring function and progressing the patient to a point where she was safe to return home with her husband. The treatment followed evidence-based clinical practice guidelines for TBI, specifically Understanding Traumatic Brain Injury by Ontario Neurotrauma Foundation and Rehabilitation Following Acquired Brain Injury by the British Society of Rehabilitation Medicine (BSRM). Thus, in-patient rehabilitation involved components of task-specific training, balance re-training, gait re-education, strength training and aerobic fitness training, all in the context of functional tasks where possible [14] .

To maximize outcomes of treatment, the in-patient rehabilitation program was adapted to use appropriate learning strategies based on the patient’s cognitive abilities. Treatment began by having a structured routine [15] , using distributed practice, explicit feedback [16] , closed environments, and clear and concise instructions. As the patient improved in cognitive and physical function, treatment progressed to using random practice schedule [17] , open environments, implicit feedback [16] and more complex cognitive tasks. To avoid fatigue, the patient’s energy levels were monitored and treatment was adapted as needed. Adaptations included: lowering frequency, intensity, and/or amount of exercises during treatment sessions. The adaptation chosen depended on her needs at the time. Upper extremity ROM and strengthening was incorporated into dynamic sitting exercises to reduce the number of exercises provided and to avoid redundancy. Finally, segments of education for both the patient and her husband were included in treatment. Education sessions included the physical, cognitive, behavioural and emotional impacts of TBI, as well as the prognosis and symptoms of TBI [14] . It was important to educate her husband on areas of treatment he could help with, and how he could support his wife throughout her prognosis [14] .

*NOTE: Treatment occurred daily, for 1-hr sessions. All of the exercises are listed below, however, not all were performed in a single treatment session. Each day of the week, treatment involved a selection of these exercises, and parameters varied, depending on the patient's tolerance. In addition, it was recommended that the patient work on these exercises outside of rehab as well, either with her husband or other staff [14] .

Patient Oriented Goals [ edit | edit source ]

Balance and Mobility [ edit | edit source ]

Treatment started with basic static sitting and standing postures. Treatment progressed to dynamic exercises after the patient tolerated static postures. These exercises were included in the program to help the patient gain balance prior to introducing more dynamic, functional and complex movements, such as walking and/or ascending and descending stairs [14] [18] .

Strength Training [ edit | edit source ]

Core strengthening and strengthening of the lower extremities helped improve coordination and efficiency of walking [18] [19] .

Flexibility/Range of Motion Training [ edit | edit source ]

Therapy focused on stretching muscle groups that have developed contractures or have tightened throughout hospital stay.

Task-Specific Training [20] [ edit | edit source ]

*Practicing with staff or PT whenever she needed/wanted to get out of bed was encouraged. Her husband was educated on how to assist her with transfers.

Gait Training [ edit | edit source ]

Ambulation is a common goal of many TBI patients, making gait training an important aspect of rehabilitation [14] [18] . However, the type of gait training varies depending on the severity of the TBI [18] . The most common forms include range of motion activities, weight shifting, and lower extremity and core strengthening, which were addressed earlier in treatment [18] [20] . However, higher level exercises such as dual-task techniques can be introduced to make treatment more engaging and functional for the patient [18] .

Aerobic Exercise Training [ edit | edit source ]

Exercise can improve cardiorespiratory fitness as well as cognitive function among patients with TBI [25] .

Progressed to leg cycling and eventually treadmill walking

Use the FITT principle

Outcome [ edit | edit source ]

4 weeks in in-patient rehabilitation (re-assessment) [ edit | edit source ].

The ROM and flexibility exercises helped normalize the patient's muscle tone, especially in the left side of the body, The left upper extremities and lower extremities showed a slight increase in extensor and flexor muscle tones, respectively, classified as Grade 1 on the Modified Ashworth Scale .

With the decrease in contracture, she was able to isolate movements on the left side of the body, which facilitated her ability to perform ADL's such as self-care. Additionally, the therapist observed her Ranchos level to be VII (automatic-appropriate), suggesting that the patient required minimal assistance in daily living skills. Similarly, her FIM score of 106 suggested that she no longer required assistance to accomplish tasks, but might require supervision to ensure safety [13] .

Additionally, gait training combined with static and dynamic balance resulted in improvement of her gait:

Discharge Planning [ edit | edit source ]

The patient was considered appropriate for discharge based on the following information:

Prior to discharge, the physiotherapist and occupational therapist had an education session with the patient and her spouse focusing on safe community ambulation and performing ADLs within the home. The patient also received a document with the same information to refer to when needed.

Her spouse was made aware of the fact that patients at Ranchos Level VII can overestimate their abilities and be unaware of the consequences of a decision [6] . As such, her husband was encouraged to talk about safety and emergency measures with the patient [28] . Furthermore, it was encouraged to do activities together, such as laundry and groceries, even though the patient does not need close supervision in performing a task [28] . The patient can be distracted, so it was encouraged to write a list of daily to do lists [28] [6] . It was possible that the patient was unaware of people’s feelings and could potentially act uncooperatively in social situations [28] . In that case, it was recommended to use a calm tone to offer feedback on such behaviour [28] .

The patient has been referred to a home-based rehabilitation program where she will be followed by a physiotherapist and an occupational therapist.

Discussion [ edit | edit source ]

The fictional case study followed a 65-year of woman attending physiotherapy in an in-patient rehabilitation unit following a craniotomy for a subdural haematoma . The initial examination findings, 2 weeks after surgery, included impaired memory, balance issues, limited ambulation and increased tone in the left and right upper extremities and left lower extremities. Physiotherapy interventions consisted of balance training, task-specific exercises, strength training, flexibility exercises, gait training and postural education. Upon reassessment of outcome measures, 4 weeks after in-patient rehabilitation, the patient showed improvement in her FIM score, Berg Balance Scale, lower muscle tone (i.e., Modified Ashworth Scale), faster gait speed and endurance.

This case study included traditional physiotherapy to improve her strength, range of motion, performance of functional tasks, transfers, and posture. In addition to traditional methods, virtual reality was used to improve her gait. Based on her outcomes, the use of virtual reality to improve gait showed promise. Although there are many studies that demonstrate the benefits of the use of virtual reality and gait training, few physiotherapists use virtual reality in practice [18] . This raises the question of whether this is due to lack of knowledge of the benefits, lack of funding or both. Future inquiry should address the barriers to implementing the use of virtual reality in physiotherapy practice and beneficial technologies regarding the rehabilitation of patients with TBIs.

Furthermore, it is important to take the patient’s cognitive status into consideration during treatment and in discharge planning. Physiotherapists in this case study tailored rehabilitation to the patient’s cognitive abilities to maximize treatment outcomes by using implicit learning early in rehabilitation, and explicit learning later in treatment. Implicit learning strategies were used early in rehabilitation because the treatment focused on functional tasks, and implicit learning ensures acquisition and retention of a given skill [16] . In contrast, explicit learning allows the patient to transfer learning to different tasks, which had higher importance after the patient mastered the skill [16] . This being said, research on motor learning strategies used in TBI patients is not clear [16] . Some studies show that implicit feedback is less impaired following a TBI, therefore it is argued that explicit feedback should be the focus in treatment [16] . Other research argues that implicit learning should be the focus [16] . Therefore, it is unclear as to which approach is better, and what sequence the learning styles should be provided during TBI rehabilitation [16] .

In summary, although the patient in this case study showed general improvements in functional ability, there are some evidence gaps regarding the effectiveness of certain rehabilitation interventions following a TBI. In particular, further research must be done on the effectiveness of implicit and explicit learning strategies, as well as the effectiveness and prevalence of virtual reality use in rehabilitation following a TBI.

References [ edit | edit source ]

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Phineas Gage: His Accident and Impact on Psychology

Kendra Cherry, MS, is an author and educational consultant focused on helping students learn about psychology.

Emily is a board-certified science editor who has worked with top digital publishing brands like Voices for Biodiversity, Study.com, GoodTherapy, Vox, and Verywell.

Author unknown / Wikimedia Commons

Frequently Asked Questions

Phineas Gage is often referred to as the "man who began neuroscience." He experienced a traumatic brain injury when an iron rod was driven through his skull, destroying much of his frontal lobe .

Gage miraculously survived the accident. However, his personality and behavior were so changed as a result of the frontal lobe damage that many of his friends described him as an almost different person entirely. The impact that the accident had has helped us better understand what the frontal lobe does, especially in relation to personality .

Phineas Gage's Accident

On September 13, 1848, 25-year-old Gage was working as the foreman of a crew preparing a railroad bed near Cavendish, Vermont. He was using an iron tamping rod to pack explosive powder into a hole.

Unfortunately, the powder detonated, sending the 43-inch-long, 1.25-inch-diameter rod hurling upward. The rod penetrated Gage's left cheek, tore through his brain , and exited his skull before landing 80 feet away.

Gage not only survived the initial injury but was able to speak and walk to a nearby cart so he could be taken into town to be seen by a doctor. He was still conscious later that evening and able to recount the names of his co-workers. Gage even suggested that he didn't wish to see his friends since he would be back to work in "a day or two" anyway.

The Recovery Process

After developing an infection, Gage spent September 23 to October 3 in a semi-comatose state. On October 7, he took his first steps out of bed, and, by October 11, his intellectual functioning began to improve.

Descriptions of Gage's injury and mental changes were made by Dr. John Martyn Harlow. Much of what researchers know about the case is based on Harlow's observations.

Harlow noted that Gage knew how much time had passed since the accident and remembered clearly how the accident occurred, but had difficulty estimating the size and amounts of money. Within a month, Gage was well enough to leave the house.

In the months that followed, Gage returned to his parent's home in New Hampshire to recuperate. When Harlow saw Gage again the following year, the doctor noted that while Gage had lost vision in his eye and was left with obvious scars from the accident, he was in good physical health and appeared recovered.

Theories About Gage's Survival and Recovery

The type of injury sustained by Phineas Gage could have easily been fatal. While it cannot be said with certainty why Gage was able to survive the accident, let alone recover from the injury and still function, several theories exist. They include:

The Effects of Gage's Injury

Harlow presented the first account of the changes in Gage's behavior following the accident. Where Gage had been described as energetic, motivated, and shrewd prior to the accident, many of his acquaintances explained that after the injury he was "no longer Gage."

Since there is little direct evidence of the exact extent of Gage's injuries aside from Harlow's report, it is difficult to know exactly how severely his brain was damaged. Harlow's accounts suggest that the injury did lead to a loss of social inhibition, leading Gage to behave in ways that were seen as inappropriate.

Some evidence suggests that many of the supposed effects of the accident may have been exaggerated and that Gage was actually far more functional than previously reported.

Severity of Gage's Brain Damage

In a 1994 study, researchers utilized neuroimaging techniques to reconstruct Phineas Gage's skull and determine the exact placement of the injury. Their findings indicate that he suffered injuries to both the left and right prefrontal cortices, which would result in problems with emotional processing and rational decision-making .

Another study conducted in 2004 used three-dimensional, computer-aided reconstruction to analyze the extent of Gage's injury. It found that the effects were limited to the left frontal lobe.

In 2012, new research estimated that the iron rod destroyed approximately 11% of the white matter in Gage's frontal lobe and 4% of his cerebral cortex.

Phineas Gage's Impact on Psychology

Gage's case had a tremendous influence on early neurology. The specific changes observed in his behavior pointed to emerging theories about the localization of brain function, or the idea that certain functions are associated with specific areas of the brain.

In those years, neurology was in its infancy. Gage's extraordinary story served as one of the first sources of evidence that the frontal lobe was involved in personality.

Today, scientists better understand the role that the frontal cortex has to play in important higher-order functions such as reasoning , language, and social cognition .

What Happened to Phineas Gage?

After the accident, Gage was unable to continue his previous job. According to Harlow, Gage spent some time traveling through New England and Europe with his tamping iron to earn money, supposedly even appearing in the Barnum American Museum in New York.

He also worked briefly at a livery stable in New Hampshire and then spent seven years as a stagecoach driver in Chile. He eventually moved to San Francisco to live with his mother as his health deteriorated.

After a series of epileptic seizures, Gage died on May 21, 1860, almost 12 years after his accident. Seven years after his death, Gage's body was exhumed. His brother gave his skull and the tamping rod to Dr. Harlow, who subsequently donated them to the Harvard University School of Medicine. They are still exhibited in its museum today.

Phineas Gage Summary

In 1948, Phineas Gage had a workplace accident in which an iron tamping rod entered and exited his skull. He survived but it is said that his personality changed as a result, leading to a greater understanding of the brain regions involved in personality, namely the frontal lobe.

A Word From Verywell

Gage's accident and subsequent experiences serve as a historical example of how case studies can be used to look at unique situations that could not be replicated in a lab. What researchers learned from Phineas Gage's skull and brain injury played an important role in the early days of neurology and helped scientists gain a better understanding of the human brain and the impact that damage could have on both functioning and behavior.

Gage died from an epileptic seizure almost 12 years after the accident. These seizures started a few months before his passing, though his health had started to decline several months before the seizures began.

The damage occurred to Phineas Gage's frontal lobe, the region of the brain at the front of the head. The frontal lobe plays a role in our ability to speak, make decisions, and move. It is also partially responsible for our personality.

Post-accident, Gage's demeanor was said to have changed from pleasant to surly and he went from being a hardworking, motivated man to a man who had trouble keeping a steady job. Some reports suggest that Gage's personality changes were exaggerated, and that they may also have been temporary, fading a couple of years after the accident.

Phineas Gage lived almost 12 years after the rod pierced his skull. He died on May 21, 1860. This would make him just short of 37 years old at the time of his death.

Gage's accident helped teach us that different parts of the brain play a role in different functions. Through studying Gage's frontal lobe damage, we gained a better understanding of what the frontal cortex does with regard to personality. We also began to know more about the effects of frontal lobe damage and how it may change a person.

Sevmez F, Adanir S, Ince R. Legendary name of neuroscience: Phineas Gage (1823-1860) . Child's Nervous System . 2020. doi:10.1007/s00381-020-04595-6

Twomey S. Phineas Gage: Neuroscience's most famous patient . Smithsonian Magazine.

Harlow JM. Recovery after severe injury to the head . Bull Massachus Med Soc . 1848. Reprinted in Hist Psychiat. 1993;4(14):274-281. doi:10.1177/0957154X9300401407

Harlow JM. Passage of an iron rod through the head . 1848. J Neuropsychiatry Clin Neurosci . 1999;11(2):281-3. doi:10.1176/jnp.11.2.281

Itkin A, Sehgal T. Review of Phineas Gage's oral and maxillofacial injuries . J Oral Biol . 2017;4(1):3.

de Freitas P, Monteiro R, Bertani R, et al. E.L., a modern-day Phineas Gage: Revisiting frontal lobe injury . The Lancet Regional Health - Americas . 2022;14:100340. doi:10.1016/j.lana.2022.100340

Macmillan M, Lena ML. Rehabilitating Phineas Gage . Neuropsycholog Rehab . 2010;20(5):641-658. doi:10.1080/09602011003760527

O'Driscoll K, Leach JP. "No longer Gage": An iron bar through the head. Early observations of personality change after injury to the prefrontal cortex . BMJ . 1998;317(7174):1673-4. doi:10.1136/bmj.317.7174.1673a

Macmillan M. An Odd Kind of Fame: Stories of Phineas Gage . MIT Press.

Damasio H, Grabowski T, Frank R, Galaburda AM, Damasio AR. The return of Phineas Gage: Clues about the brain from the skull of a famous patient . Science . 1994;264(5162):1102-5. doi:10.1126/science.8178168

Ratiu P, Talos IF. Images in clinical medicine. The tale of Phineas Gage, digitally remastered . N Engl J Med . 2004;351(23):e21. doi:10.1056/NEJMicm031024

Van Horn JD, Irimia A, Torgerson CM, Chambers MC, Kikinis R, Toga AW. Mapping connectivity damage in the case of Phineas Gage . PLoS One . 2012;7(5):e37454. doi: 10.1371/journal.pone.0037454

Shelley B. Footprints of Phineas Gage: Historical beginnings on the origins of brain and behavior and the birth of cerebral localizationism . Archives Med Health Sci . 2016;4(2):280-6. doi:10.4103/2321-4848.196182

Garcia-Molina A. Phineas Gage and the enigma of the prefrontal cortex . Neurologia . 2012;27(6):370-5. doi:10.1016/j.nrleng.2010.03.002

Johns Hopkins Medicine. Brain anatomy and how the brain works .

By Kendra Cherry Kendra Cherry, MS, is an author and educational consultant focused on helping students learn about psychology.

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Brainwashed: 3 of Psychology’s Greatest Case Studies

Traumatic Brain Injury (TBI) is a serious, debilitating, and usually lethal injury resulting from trauma to the head. It is alarmingly common, with around 1.7 million Americans suffering from it. If your injury is because of someone’s negligent actions, however, call a brain injury lawyer in your locality to help you with compensation.

Brain injury can take many forms; some might even remain stagnant months after an accident . Often times, however, they manifest quite obviously. Not only lethal, those suffering from TBI might also experience some life-altering changes to their physical, cognitive, psychosocial, and emotional abilities

Case studies in psychology help experts understand how the human mind works. In this case, the following case studies all have something to do with brain injury. Here are three of the greatest case studies in the field of psychology related to brain injury:

1. Phineas Gage

The case of Phineas Gage is one of the most interesting instances of brain injury throughout history. According to historical records, Gage was tamping explosives to the ground at Central Vermont in 1848 for a new railway line when he encountered a terrible accident.

One of the explosives he was handling detonated prematurely, launching his tamping iron straight to his face. The iron went right through his brain and popped out from the top of his head. Astonishingly, he was able to survive. There were, of course, lasting consequences after suffering an injury of this size.

Aside from permanent physical injuries, he sustained behavioral changes as well. He became listless and aggressive, seemingly an effect of the frontal brain damage affecting his personality.

2. Henry Gustav Molaison

Henry Gustav Molaison, who has suffered epilepsy since he was a child, opted to undergo brain surgery to treat his childhood condition. Molaison’s surgery involved taking out huge chunks of his hippocampus on either side of his brain as an attempt to treat his epilepsy.

This, later on, proved disastrous as this second case study, just at the tender age of 27, developed severe amnesia . Studies show that he was unable to retain any information in his long-term memory, going on to forget anything post-surgery.

At the time, experts thought that memory was distributed equally throughout the cerebral cortex. This is why they were so baffled by the extremity of Molaison’s condition. His unique condition spurred several other experts to literally dissect his brain and preserve it as a 3D digital atlas.

3. Victor “Tan” Leborgne

The peculiar case of Victor “Tan” Leborgne spurred psychologist’s to change their views against language function and how this was distributed through the brain. Leborgne, a Frenchman, had a speech impediment, and could only utter “tan,” besides the expletive phrase “sacre nom de Dieu”.

In 1861, he was referred to Paul Broca, a neurologist, for diagnosis and treatment. He died not long after. Broca then examined his brain and noticed a lesion in his left frontal lobe. Coupled with the knowledge of his impaired speech but normal comprehension, he deducted this part was responsible for speech production.

Suffering brain injuries , especially at the hands of another person, can be extremely traumatizing, and the road to recovery may be long and expensive. Luckily, nowadays healthcare is a lot more accessible than it was several years ago.

You no longer have to suffer through the consequences of botched brain procedures or negligent head trauma from the hands of another person. You now have experts like brain injury lawyers to help you make a claim and receive just compensation.

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