Monthly Archives: January 2019

A Broader Definition of Day Care

No one wants a life of twiddling their thumbs, with little to occupy their time.  For this reason, the concept of adult day programs was created.*  As the geriatric population becomes larger, the idea of providing appropriate funding to attend these adult day centers has become more popular.  This year, on January 8**, Rep. Barbara Lee (CA) introduced the Adult Day Center Enhancement Act to broaden the idea of who may benefit and should receive funding for adult day center attendance.  The purpose of the Act is to provide funding for, “a program that provides comprehensive and effective services to individuals living with neurological diseases or conditions… that may result in a functional or degenerative disability and to their family caregivers and that may assist participants.”  (This bill funds daytime assistance to the young adults who are disabled, however I can find no information regarding the age limits.)

Related to its assistance to the participant, “adult day programs can offer services, including medical care, rehabilitation therapies, dignified assistance with the activities of daily living, nutrition therapy, health monitoring, social interaction, stimulating activities, and transportation.”  First introduced in 2013, and re-introduced every other year thereafter, H.R. 320 seeks to maintain the quality of life of the disabled population.  As with inflation, the allowed funding will increase every year until 2023.  (The Veterans Home Adult Day Health Care Improvement Act, to which I assume partially refers to veterans with brain injuries, was signed into law on March 27, 2018.)

On January 8, the Adult Day Center Enhancement Act was referred to the House Committee of Energy and Commerce, of which Rep. Lee is a member.  (Last time the Act was introduced, it was referred to the Subcommittee on Health.)  Due to the shutdown, this bill currently has no co-sponsors nor does it have a summary on congress.gov.  Now that the shutdown is over and before the bill may be enacted, it must be evaluated by the Assistant Secretary of Aging.

* On some sites, I have found it titled “adult day care”.  However, it is generally titled “adult day programs” assumedly because “daycare” has a youth connotation.  If one is to think about it though, that inaccurately marks toddlers as the only segment of the population that needs activity during the day.

** I find it heartening that a bill was introduced in Congress during the partial shutdown, which officially began December 22, 2018.

Sex in the Brain: Sexual Disinhibition

One of the major negative effects of a TBI is disinhibition, which can manifest itself in many ways.  Social disinhibition, the most common and most discussed, is the result of an injury to the prefrontal cortex, which can be found in the frontal lobe of the brain.  Less discussed, but equally important, is sexual disinhibition, which involves taking action on sexual impulses, such as through the previously-mentioned hypersexuality, as well as through other behaviors.

The biological human need for sex is instinctual, developed in the most primitive part of the brain, the brain stem.  Sexual arousal, however, is formed in the prefrontal cortex, which controls executive functioning.  While most studies begin the summary of their findings by noting that “little research has been done”, many arousal locations have been found: “Activation of numerous frontal regions, including the right prefrontal cortex, anterior cingulate cortex and gyrus and orbitofrontal region has been observed during sexual arousal involving masturbation induced orgasm. Orbitofrontal activation has been interpreted as being related to the representation of pleasant bodily sensations, while dorsal anterior cingulate activation has been attributed to the modulation of skeletomotor activities that characterize sexual arousal and the perceived urge to act.”

Behavior control, including impulse control, is also formed in the prefrontal cortex of the brain.  When you combine increased sexual arousal with decreased self-control, foresight, attention and reasoning, the consequences may include inappropriate, illegal and/or harmful behavior.  Sexually offensive behavior, for example, is always inappropriate and known to appear in 3.5 to 9% of adults affected with brain injury.  A preoccupation with sexual thoughts presumably led two women with brain injuries to become dominatrixes.  “[One woman] began working as a stripper, then as a dominatrix, using the name Sasha Mizaree. She even built a dungeon in her apartment but said she doesn’t have sex with her clients. She was paid $250 an hour to dominate them,” reported ABC News.

While those with TBI may have an increased libido, they also have a decreased sense of self-awareness and awareness of what is appropriate.  One may no longer be able to neurologically control their aggression and other impulsive behaviors like grabbing or compulsive masturbation.  Lack of sexual control can result in such behaviors as attempted rape.  In Australia, a man who had a motorcycle accident, decades ago, was sentenced to jail for 19 years as a pedophile and child rapist.  Interestingly, many of those with TBIs who have extreme sexual behavior report no enjoyment in the activity.

Unfortunately, even with a multitude of studies that reference it, the NIH recently reported that doctors and rehabilitation facilities do not generally know how to treat the thoughts and actions that may come from from sexual disinhibition.

Skiing Into a Head Injury

Gliding down a ski slope at 60 mph, taking a ramp that lifts you up in the air with a heavy board attached to your feet and just snow below, or racing against others while doing both.  These three activities are all part of the winter routine for individuals who enjoy the extreme sports of freestyle skiing, snowboarding or snowcross.  Extreme sports are, by definition, dangerous.  A Google search of snowboarding, for example, found two pages of articles related to snowboarding deaths and accidents this year alone.

First coming into existence either in the 1950s, 1960s or 1970s, depending on which source you reference, extreme sports tap into a person’s sense of adventure.  Head and neck injuries due to winter extreme sports are common, when compared to other sports, partly because, “many extreme sports take place in environments where medical care may not be readily available.”

Throughout the years, extreme sports have become more popular, perhaps as the opportunity for adventure and physical risk of everyday life goes down and mental stress goes up.  Head and neck injuries due to winter extreme sports have also significantly increased through the years.  There is a cost to these injuries, both emotionally for the individual and monetarily for both the individual and the government through evacuation costs, rehabilitation costs and community costs in the future.  This month, the government pays more attention to these risks, as well as the needed research, as January is National Winter Sports Traumatic Brain Injury Awareness Month.

Although finding new means to treat traumatic brain injury in extreme winter sports is very important, “prevention is the top priority”.  The Office of Disease Prevention and Health Promotion reminds people to always wear a helmet and to make sure to watch your surroundings by staying in the boundaries in ski slopes and watching for obstacles and hazards on your path.  Just as importantly, “make sure medical care is close.”  Additionally, Dr. Pickett of the National Intrepid Center of Excellence reminds people that, “It’s important to consider how weather conditions… increase the risk for these injuries.”  While equipment is now safer and access to medical care has improved, prevention should always come first.  If you enjoy the thrill of extreme winter sports, I hope you enjoy it this winter, but know and use all available information to make it safe.

Weighing In On Insomnia

Sleep is crucial for humans to survive and thrive.  “Emerging evidence implicates sleep in the most basic of neurological functions, namely the exchange of metabolic wastes associated with neurological homeostasis…  sleep is integral in the function of the glymphatic system… Natural sleep or anesthesia accounts for an increase in interstitial space that facilitates the subsequent exchange of cerebrospinal fluid (CSF) with interstitial fluid.”  All people have been told to get at least 8 hours of sleep a night.  While this number is actually higher for the young, 7-8 hours is the recommended hours of sleep needed for those 18 and up.  For those with brain injuries, an energized brain is necessary to perform at their best.  However, about 30 to 70 percent of those with brain injuries have sleep disorders including deprivation, deficiency, disruption, etc.  (Although fatigue may be the most obvious side effect of a sleep disorder, “the consequences of disrupted sleep following injury range from deranged metabolomics and blood brain barrier compromise to altered neuroplasticity and degeneration.”)

The above links are all from government studies into brain injury and sleep disorders.  While they may be interesting and informative, methods of curing these sleep disorders are what really matter to those afflicted with them.  So far, many means to induce sleep and reduce the activity of a restless mind have been explored and written about, such as cognitive behavioral therapy, the use of activities, etc.

My advice is to read the results of these studies while you’re in bed, using one of the recommended sleep aids: a weighted blanket.  Weighted blankets have gained popularity in the past few years.  So named because the weight of the blanket equals about 10 percent of the user’s weight, the extra weight that this blanket provides the user is soothing, rather than encapsulating.  They are a form of deep pressure touch stimulation, which can help with one of the more common symptoms of TBI, anxiety, among other things.  (I am not promoting weighted blankets more than cognitive behavior therapy or any other means of ridding one’s self of a sleep disorder, I’m just on the search for a new sleep strategy.)

Sex in the Brain: Hypersexuality

During the winter, when the cooler weather keeps people indoors, sex may have a more prominent part in the lives of many couples.  Since the feelings that ultimately result in sex are developed in the brain, they can be altered by a brain injury.  Additionally, since the desire for sex is neurological, if, when and with whom someone wants to have sex can be changed by a brain injury.  Finally, how someone expresses their feelings following a brain injury may be altered.  Today, I present the first of several articles that showcases federal research and other important information regarding the expression of libido in those with brain injuries in an article series entitled Sex in the Brain:

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A 43-year-old man was in an auto accident.  The accident left the man in a coma and having seizures for three weeks.  Upon regaining full consciousness, while still in the hospital, he masturbated multiple times a day for the next 2 weeks…. A 33-year-old married woman with children was in a car crash that caused a moderate head injury.  Though it was 2 weeks until she regained full consciousness and though she had aphasia for 4 weeks, X-rays of the skull showed no abnormalities in the brain.  However, while at the hospital, she flashed a female visitor and consistently, “demanded to go home to fulfill her sexual urge.”

The above two stories are some of the clinical data from a 2008 study regarding hypersexuality, also known as compulsive sexual behavior, following brain injury.  Hypersexuality, previously termed nymphomania in men and satyriasis in women, is, “the inability to regulate one’s sexual behavior that is a source of significant personal distress.”  It is about the object of sex, as opposed to the relationship.  Sexual fantasies, urges and behavior become a preoccupation that is difficult to control, causes distress and ultimately has negative effects on one’s health and life.  Its presentation can be in numerous ways, such as through excessive and public masturbation, an excessive number of sexual partners, an excessive use of pornography and/or paying for sex.  If this occurs for over 6 months, it is considered an addiction, specifically a process addiction like gambling, binge eating or compulsive spending.

Also, like any other addiction, hypersexuality has a neurological basis and, therefore, can be either a primary diagnosis or secondary diagnosis caused by another disorder, such as bipolar disorder, dementia or traumatic brain injury, among other disorders, or caused by medication, like dopamine agonist.  Neurologically, it is caused by an injury to the frontal lobe.  Though it may be a sensational topic, it is rare.  (It is more common among those arrested for exhibitionism than it is for the general public.  “Between 5 and 35% of those arrested for exhibition are found to be suffering from organic disorders to which the behavior can be at least partially attributed.”)  Additionally, it is more common in men.

Despite all the federal research to prove it as a unique impulse control issue, when the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) came out in October 2017, hypersexuality was not included.  (Hypersexuality and compulsive sexual behavior both fell under the “sexual disorders not otherwise specified” category in DSM-4.)  That year, though, the NIH did develop a new defining phrase to explain actions that occur due to the disorder: the sexhavior cycle of hypersexuality.

Brain Injury Task Force Loses a Chair

This week, the 116th Congress was sworn in on Capitol Hill.  Unfortunately, that means that the Congressional Brain Injury Task Force lost one of its Chairs, Congressman Thomas Rooney (FL), who did not seek reelection.

Having served in the Army for 4 years in combat and 4 years in the reserve, Rooney accorded special attention to brain injury in the military on the Task Force.  This summer, it was reported, “House Approves Rooney-Requested Funding for Traumatic Brain Injuries.”  (Seen now on the website VoteSmart, this article is a repost first seen on the official Congressional website for Rooney, which is now defunct.)  The requested funding given was $125 million.

As a member of the House Appropriations Committee, Rooney dealt with the financing of government bills and other such actions.  (The House Ways and Means Committee is also focused on financial needs, a Committee that counts co-chair of the Brain Injury Task Force Congressman Pascrell as a member.)  Of this victory, Rooney stated, “The reality is our service members take great risks when they enlist to fight for our country. One of the biggest risks is TBIs, which can lead to severe mental health issues like depression and even suicide. These problems are serious and real and each dollar we spend towards research and treatment puts us one step closer to helping our military.”  (It is important to note that the VA conducts research that benefits all Americans, not simply those in the armed forces.)

Rooney is succeeded in Florida’s 17th District by former State Legislator Greg Steube.  Like his predecessor, Steube is a veteran with 4 years in combat.  Hopefully, Steube will have as much consideration for brain injury as his predecessor, too.