Category Archives: brain injury

Good news: New hope for victims of traumatic brain injury

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Every year, nearly two million people in the United States suffer traumatic brain injury (TBI), the leading cause of brain damage and permanent disabilities that include motor dysfunction, psychological disorders, and memory loss. Current rehabilitation programs help patients but often achieve limited success.

Now Dr. Shai Efrati and Prof. Eshel Ben-Jacob of Tel Aviv University’s Sagol School of Neuroscience have proven that it is possible to repair brains and improve the quality of life for TBI victims, even years after the occurrence of the injury.

In an article published in PLoS ONE, Dr. Efrati, Prof. Ben Jacob, and their collaborators present evidence that hyperbaric oxygen therapy (HBOT) should repair chronically impaired brain functions and significantly improve the quality of life of mild TBI patients. The new findings challenge the often-dismissive stand of the US Food and Drug Administration, Centers for Disease Control and Prevention, and the medical community at large, and offer new hope where there was none.

The research trial

The trial included 56 participants who had suffered mild traumatic brain injury one to five years earlier and were still bothered by headaches, difficulty concentrating, irritability, and other cognitive impairments. The patients’ symptoms were no longer improving prior to the trial.

The participants were randomly divided into two groups. One received two months of HBOT treatment while the other, the control group, was not treated at all. The latter group then received two months of treatment following the first control period. The treatments, administered at the Institute of Hyperbaric Medicine at Assaf Harofeh Medical Center, headed by Dr. Efrati, consisted of 40 one-hour sessions, administered five times a week over two months, in a high pressure chamber, breathing 100% oxygen and experiencing a pressure of 1.5 atmospheres, the pressure experienced when diving under water to a depth of 5 meters. The patients’ brain functions and quality of life were then assessed by computerized evaluations and compared with single photon emission computed tomography (SPECT) scans.

Persuasive confirmation

In both groups, the hyperbaric oxygen therapy sessions led to significant improvements in tests of cognitive function and quality of life. No significant improvements occurred by the end of the period of non-treatment in the control group. Analysis of brain imaging showed significantly increased neuronal activity after a two-month period of HBOT treatment compared to the control periods of non-treatment.

“What makes the results even more persuasive is the remarkable agreement between the cognitive function restoration and the changes in brain functionality as detected by the SPECT scans,” explained Prof. Ben-Jacob. “The results demonstrate that neuroplasticity can be activated for months and years after acute brain injury.”

“But most important, patients experienced improvements such as memory restoration and renewed use of language,” Dr. Efrati said. “These changes can make a world of difference in daily life, helping patients regain their independence, go to work, and integrate back into society.”

The regeneration process following brain injury involves complex processes, such as building new blood vessels and rebuilding connections between neurons, and requires much energy.

“This is where HBOT treatment can help,” said Dr. Efrati. “The elevated oxygen levels during treatment supply the necessary energy for facilitating the healing process.”

The findings offer new hope for millions of traumatic brain injury patients, including thousands of veterans wounded in action in Iraq and Afghanistan. The researchers call for additional larger scale, multi-center clinical studies to further confirm the findings and determine the most effective and personalized treatment protocols. But since the hyperbaric oxygen therapy is the only treatment proven to heal TBI patients, the researchers say that the medical community and the US Armed Forces should permit the victims of TBI benefit from the new hope right now, rather than waiting until additional studies are completed.

9 Things NOT to Say to Someone with a Brain Injury

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Brain injury is confusing to people who don’t have one. It’s natural to want to say something, to voice an opinion or offer advice, even when we don’t understand.

And when you care for a loved one with a brain injury, it’s easy to get burnt out and say things out of frustration.

Here are a few things you might find yourself saying that are probably not helpful:

1. You seem fine to me.

The invisible signs of a brain injury — memory and concentrationproblems, fatigue, insomnia, chronic pain, depression, or anxiety — these are sometimes more difficult to live with than visible disabilities. Research shows that having just a scar on the head can help a person with a brain injury feel validated and better understood. Your loved one may look normal, but shrugging off the invisible signs of brain injury is belittling. Consider this: a memory problem can be much more disabling than a limp.

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2. Maybe you’re just not trying hard enough (you’re lazy).

Lazy is not the same as apathy (lack of interest, motivation, or emotion). Apathy is a disorder and common after a brain injury. Apathy can often get in the way ofrehabilitation and recovery, so it’s important to recognize and treat it. Certain prescription drugs have been shown to reduce apathy.Setting very specific goals might also help.

Do beware of problems that mimic apathy. Depression, fatigue, andchronic pain are common after a brain injury, and can look like (or be combined with) apathy. Side effects of some prescription drugs can also look like apathy. Try to discover the root of the problem, so that you can help advocate for proper treatment.

3. You’re such a grump!

Irritability is one of the most common signs of a brain injury. Irritability could be the direct result of the brain injury, or a side effect of depression, anxiety, chronic pain, sleep disorders, or fatigue. Think of it as a biological grumpiness — it’s not as if your loved one can get some air and come back in a better mood. It can come and go without reason.

It’s hard to live with someone who is grumpy, moody, or angry all the time. Certain prescription drugs, supplements, changes in diet, or therapy that focuses on adjustment and coping skills can all help to reduce irritability.

4. How many times do I have to tell you?

It’s frustrating to repeat yourself over and over, but almost everyone who has a brain injury will experience some memory problems. Instead of pointing out a deficit, try finding a solution. Make the task easier. Create a routine. Install a memo board in the kitchen. Also, remember that language isn’t always verbal. “I’ve already told you this” comes through loud and clear just by facial expression.

5. Do you have any idea how much I do for you?

Your loved one probably knows how much you do, and feels incrediblyguilty about it. It’s also possible that your loved one has no clue, and may never understand. This can be due to problems with awareness, memory, or apathy — all of which can be a direct result of a brain injury. You do need to unload your burden on someone, just let that someone be a good friend or a counselor.

6. Your problem is all the medications you take.

Prescription drugs can cause all kinds of side effects such as sluggishness, insomnia, memory problems, mania, sexual dysfunction, or weight gain — just to name a few. Someone with a brain injury is especially sensitive to these effects. But, if you blame everything on the effects of drugs, two things could happen. One, you might be encouraging your loved one to stop taking an important drug prematurely. Two, you might be overlooking a genuine sign of brain injury.

It’s a good idea to regularly review prescription drugs with a doctor. Don’t be afraid to ask about alternatives that might reduce side effects. At some point in recovery, it might very well be the right time to taper off a drug. But, you won’t know this without regular follow-up.

7. Let me do that for you.

Independence and control are two of the most important things lost after a brain injury. Yes, it may be easier to do things for your loved one. Yes, it may be less frustrating. But, encouraging your loved one to do things on their own will help promote self-esteem, confidence, and quality of living. It can also help the brain recover faster.

Do make sure that the task isn’t one that might put your loved one at genuine risk — such as driving too soon or managing medication when there are significant memory problems.

8. Try to think positively.

That’s easier said than done for many people, and even harder for someone with a brain injury. Repetitive negative thinking is called rumination, and it can be common after a brain injury. Rumination is usually related to depression or anxiety, and so treating those problems may help break the negative thinking cycle.

Furthermore, if you tell someone to stop thinking about a certain negative thought, that thought will just be pushed further towards the front of the mind (literally, to the prefrontal cortex). Instead, find a task that is especially enjoyable for your loved one. It will help to distract from negative thinking, and release chemicals that promote more positive thoughts.

9. You’re lucky to be alive.

This sounds like positive thinking, looking on the bright side of things. But be careful. A person with a brain injury is six times more likely to have suicidal thoughts than someone without a brain injury. Some may not feel very lucky to be alive. Instead of calling it “luck,” talk about how strong, persistent, or heroic the person is for getting through their ordeal. Tell them that they’re awesome.

Natural Cures for a Brain Injury

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Aside from team rivalries and all out victories, brain injuries are one of the hottest topics in sports today. According to the American Association of Neurological Surgeons, sports and recreational activities alone are responsible for nearly 21% of brain injuries. No matter how you have developed an injury, though, you can employ a number of different methods to treat the condition, incorporating necessary medical attention as well as natural cures like omega-3 fats and turmeric.

What Is a Brain Injury?

Mayo Clinic explains a brain injury, or traumatic brain injury (TBI), as a condition that occurs when an external force causes brain dysfunction. The most common causes of TBI are a violent blow to your head or a jolt to your head and/or body. An object permeating the surface of your skull can also cause significant brain injury.

The prevalence of symptoms associated with a brain injury vary depending on the severity of your condition. Additionally, some symptoms may occur directly following the event or not manifest until days or even weeks later. Nevertheless, common signs of a brain injury include loss of consciousness, headache, nausea, vomiting, fatigue, difficulty sleeping, and dizziness. Other symptoms include sensory issues such as blurred vision, sensitivity to light or sound, memory or concentration problems, and mood changes.

Do Natural Cures Help Recovery from a Traumatic Brain Injury?

It is absolutely necessary to consult a medical professional when you suspect a traumatic brain injury. However, there are many natural remedies that help expedite recovery from a brain injury. Herbal remedies that offer support for TBI include options such as omega-3 fats, turmeric, and gingko. Likewise, treatments such as acupuncture and massage have also shown to be beneficial for treating brain injuries.

1. Omega-3 Fats

When you consider the composition of your brain, it is actually 60% fat, constructed from omega-3 fats. A daily supplement of omega-3s inhibits cell death, helps promote the reconnection of damaged neurons in the brain, and activate specific genes that help you cope with brain damage. Dr. Mercola suggests two to three 500mg capsules of krill oil, a natural omega-3 fat, each day for the best benefits.

2. Turmeric

The Vermont Center for Integrative Herbalism supports use of turmeric as a natural treatment for brain injury. Turmeric contains an important compound known as curcumin, which is used for relieving inflammation in the system. It also helps promote the functioning of the brain and promotes effective blood flow throughout your body to ensure you are getting plenty of oxygen flow to your brain. For the best results, take a 500mg capsule of turmeric up to four times a day.

3. Gingko

Gingko biloba is another treatment option purported by the Vermont Center. This treatment contains glycosylated flavonoids that help reduce inflammation in your brain following an injury. This treatment also promotes circulation to the brain and improves moods. Take 240mg to 480mg of the extract daily.

4. Acupuncture

The Brain Injury Recovery Network also suggests alternative therapies, like acupuncture for effective treatment. With a focus on rebalancing your body, acupuncture may help treat your symptoms as well as the actual damage to your brain.

5. Massage

While massage may not seem like a directly related treatment for TBI, it helps restore proper function throughout your body. It also helps improve circulation, the flow of lymph fluid, and the metabolism of wastes in your body, which all work to rejuvenate your brain.

German Scientists Find Headbanging Can Cause Brain Injuries, Confirm This Makes Motorhead Super Hardcore

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Sad news, metal lovers: German scientists have found that headbanging can be harmful, and can even potentially make your brain bleed. Wait, so you mean that whipping my head back and forth to loud music for hours on end is actually bad for me? Shocking. On the upside, though, the scientists also officially confirmed that Motorhead is “one of the most hardcore rock’n’roll acts on Earth.” So…rock on?

Veteran headbangers will know that there’s more than one way to headbang out there. It’s not just a vigorous nod; it’s a whole body experience. There’s the windmill. There’s the headslam. (If you want the definitive guide on just how to headbang, here’s a handy cheat sheet.) Unsurprisingly, these things are not good for you — your brain just wasn’t built to slosh around in your skull toAce Of Spades. And science has confirmed as much in a study published in The Lancet Thursday.

The study details the case of a 50-year-old metalhead who went to the doctors at Hannover Medical School last year with a headache that just wouldn’t go away. A head scan found a chronic subdural hematoma — otherwise known as bleeding in the brain. But the cause was a mystery, until they found out that he’d been at a Motorhead concert with his son less than a month before. “He had no history of head trauma, but reported headbanging at a Motörhead concert 4 weeks previously,” says the study.

The man’s clot had to be removed via a hole drilled into his skull — shudder — and then draining the brain for just under a week. Although the man recovered completely, doctors confirmed that “headbanging, with its brisk forward and backward acceleration and deceleration forces, led to rupturing of bridging veins causing hemorrhage.” Ouch.

Before you cancel your Fourth of July rave, bear in mind the case is one of only four others in which headbanging has led to serious brain injury. As theGuardian reports, there have been three other documented incidents of headbanging leading to blood clots — one of them led to a sudden death. More common medical issues, though, are things like whiplash and sore necks.

Said the scientists: “This case serves as evidence in support of Motorhead’s reputation as one of the most hardcore rock’n’roll acts on Earth, if nothing else because of their music’s contagious speed drive and the hazardous potential for headbanging fans to suffer brain injury.”

Hardcore and metal certainly go together, but other types of music are also risky in their own ways. Just two weeks ago, a teen lost his finger and kept dancing at a London rave; just over a week ago, an Avicii concert sent 36 fans to hospital with injuries relating to drugs and alcohol intoxication.

“We are not against headbanging,” said Dr Ariyan Pirayesh Islamian, one of the doctors who treated the headbanger. “The risk of injury is very, very low. But I think if [the patient] had gone to a classical concert, this would not have happened.” So you might think, Dr. Islamian — but classical music concertscan get a lil’ wild too, sometimes.

What Impact Will Moderate or Severe TBI Have on a Person’s Life?

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In considering the long-term effects of TBI on the individual, it is most important to emphasize that there is no “typical” person with TBI. People who have experienced a TBI vary on many dimensions: 1) severity of initial injury; 2) rate and completeness of physiological healing; 3) types of functions affected; 4) meaning of dysfunction in the individual’s life, in the context of his/her roles, values, and goals; 5) resources available to aid recovery of function; and so forth. Thus, the most important point to emphasize is that the consequences will be different for each individual injured.

In discussing possible effects of TBI, the immediate physiological recovery (which may continue over months and years) was discussed in a prior question. When the moderately or severely injured person has completed this initial recovery, the long-term functional deficits associated with TBI come to the fore. What areas of functioning may be affected by injury to the brain? Any or all of the functions the brain controls may be impacted. However, given that individuals differ greatly in their response to injury, any specific individual may experience only one, a few, or most of the possible effects. Further, a change in any of the possible areas of dysfunction, if it occurs at all, will vary in intensity across individuals – from very subtle to moderate to life threatening.

It is important to be aware also that not all functions of the individual are impacted by TBI. For example, feelings toward family, long-term memories, the ability to ski or cook, one’s knowledge of the world, and so forth – all may be intact, along with numerous other characteristics of an individual, even one who has experienced a moderate to severe injury.

The possible long-term effects of moderate-to-severe brain injury are discussed in the following three questions.

How are thinking and other aspects of cognition affected?

Individuals with a moderate-to-severe brain injury most typically experience problems in basic cognitive skills: sustaining attention, concentrating on tasks at hand, and remembering newly learned material. They may think slowly, speak slowly, and solve problems slowly. They may become confused easily when normal routines are changed or when the stimulation level from the environment exceeds their threshold. They may persevere at tasks too long, being unable to switch to a different tactic or a new task when encountering difficulties. Or, on the other hand, they may jump at the first “solution” they see, substituting impulsive responses for considered actions. They may be unable to go beyond a concrete appreciation of situations, to find abstract principles that are necessary to carry learning into new situations. Their speech and language may be impaired: word-finding problems, understanding the language of others, and the like.

A major class of cognitive abilities that may be affected by TBI is referred to as executive functions – the complex processing of large amounts of intricate information that we need to function creatively, competently and independently as beings in a complex world. Thus, after injury, individuals with TBI may be unable to function well in their social roles because of difficulty in planning ahead, in keeping track of time, in coordinating complex events, in making decisions based on broad input, in adapting to changes in life, and in otherwise “being the executive” in one’s own life.

With appropriate training and other supports, the person may be able to learn to compensate for some of these cognitive difficulties.

The TBI Research Center at Mount Sinai is conducting research to help people with TBI who experience cognitive difficulties. Descriptions of these studies are found at Rehabilitation Trials.

How are mood and behavior affected?

With TBI, the systems in the brain that control our social-emotional lives often are damaged. The consequences for the individual and for his or her significant others may be very difficult, as these changes may imply to them that “the person who once was” is “no longer there.” Thus, personality can be substantially or subtly modified following injury. The person who was once an optimist may now be depressed. The previously tactful and socially skilled negotiator may now be blurting comments that embarrass those around him/her. The person may also be characterized by a variety of other behaviors: dependent behaviors, emotional swings, lack of motivation, irritability, aggression, lethargy, being very uninhibited, and/or being unable to modify behavior to fit varying situations.

A very important change that affects many people with TBI is referred to as denial (or, lack of awareness): The person becomes unable to compare post-injury behavior and abilities with pre-injury behavior and abilities. For these individuals, the effects of TBI are, for whatever reason, simply not perceived – whether for emotional reasons, as a means of avoiding the pain of fully facing the consequences of injury, or for neurological reasons, in which brain damage itself limits the individual’s ability to step back, compare, evaluate differences, and reach a conclusion based on that process.

With appropriate training, therapy, and other supports, the person may be able to reduce the impact of some of these emotional and behavioral difficulties.

The TBI Research Center at Mount Sinai is conducting research to help people with TBI who experience depression and other mood disturbances. Descriptions of these studies are found at Rehabilitation Trials.

What other changes are likely after moderate/severe TBI?

Any of the ways we have of sensing/perceiving may be affected by TBI. Vision may be affected in many ways: loss of vision, blurred visual images, inability to track visual material, loss of parts of the field of vision, reduced depth perception, and sometimes disconnection between visual perception and visual comprehension, so that the person does not know what he or she is seeing. Changes also may occur in the senses of hearing, smell, taste, and touch; the individual may become overly sensitive or insensitive. Further, the person may have difficulty sensing the location of his/her own body in space. Other individuals with TBI may have recurring problems with balance, vertigo, and ringing in the ears.

A relatively small percent of individuals with TBI experience seizures. For most of these, the initial onset of seizures occurs soon after injury. For others, the onset may take place up to several years post-injury. Two types of seizures may occur. Major motor seizures refer to what were once called grand mal seizures and involve loss of consciousness and vigorous, uncontrolled movement of the major muscle systems. Local motor seizures do not lead to loss of consciousness and involve less muscle movement. Some individuals with TBI use anticonvulsive drugs to prevent seizures or stop them during the course of a seizure.

If motor areas of the brain are damaged, the person with TBI may experience varying degrees of physical paralysis or spasticity, affecting a wide variety of behavior from speech production to walking. Damage to brain tissue can also evidence itself in chronic pain, including headaches. Also, evidence is growing that hormonal, endocrine, and other body systems are affected by the brain injury. Consequently, the individual may lose control of bowel and bladder functions, may sleep poorly, may fatigue easily, may lose appetite for food or be unable to control eating, and/or may be unable to regulate body temperature within normal boundaries. Women with TBI often experience menstrual difficulties. Some of our research on post-TBI health and medical issues is discussed in TBI Consumer Report No. 1.

The TBI Research Center at Mount Sinai is conducting research to help people with TBI who experience fatigue. A description of this study is found at Rehabilitation Trials.

Why are we poor at predicting outcome?

The severity of the injury and the resulting direct effects on the individual’s body systems may not predict the amount of impact in a person’s life. This follows, first and foremost, because each of us draws in different ways on differing parts of our brains. For example, a severe injury to the frontal brain area may have less impact on an agricultural worker’s job performance than a relatively mild frontal injury would have on a physicist’s work. In sum, the meaning of the various patterns of injury and the associated changes in any person’s life will depend on preinjury lifestyle, personality, goals, values, resources, as well as the individual’s ability to adapt to changes and to learn techniques for minimizing the effects of brain injury.

We know in general that the variability of patterns of change associated with brain injury are shaped by many factors: the severity of injury and age at injury, time in coma, time since injury, length of PTA, the resources and services available to the injured person, the barriers met or advantages offered within different social contexts, the social and role demands that exist within the individual’s life, and so on. How these factors work, in what ways, and how often is not clear. We know that TBI hits people differently, but have less knowledge of the number of people that experience various types of consequences and the specific factors affecting this.

What can I do to help the process of recovery?

Immediately after injury, friends and family who want to help should focus on insuring that the injured person receives medical care that will minimize the effects of injury. This usually means that the person should be receiving care in a medical center that specializes in trauma care. This topic is covered more fully in another question, What Is the Course of Treatment for Those with Moderate/Severe TBI?

Once issues of life-and-death have been addressed, the person’s functioning as a cognitive, emotional, and social entity comes to the fore. The individual is faced with many or a few of the possible changes described in preceding questions.

It has been suggested (by Kay and Lezak in 1990) that “recovery” is a misnomer and that “improvement” better describes what happens in the long run after TBI. The word recovery may, inappropriately, suggest that the effects of TBI will disappear, similar to symptoms vanishing when we recover from a cold. With TBI, some of the effects may truly dissipate after one year, two years, or more, but more frequently these long-term changes linger on, subtly or not so subtly, changing only slowly, if at all, over the life course.

What must be kept in mind at all times is that impairments that are due to injury of brain tissue can be helped through reeducation of the individual and through modification of the environment. Thus, for example, although the brain circuits involved in memory may never function in the ways and at the levels found before injury, remembering (a necessary skill in day-to-day life) may be improved by the individual’s learning compensatory skills, such as using a daily diary to remember appointments, and by adjusting parts of the environment (alarm clocks, computer reminder programs, and family members) to jog memory.

The boundary of improvement is set by the individual’s ability to learn new ways of doing things or to relearn formerly familiar skills. Since the brain mediates all learning and the brain is damaged, learning is often slow and/or incomplete.

The major role for friends and family at this stage of recovery is to help find resources that will help the injured person in addressing emotional, cognitive, physical, and behavioral challenges. A variety of resources are available on this Web site, including publications, linkages to other Web sites and information about rehabilitation trials that may help people with cognitive difficulties, mood disorders and fatigue.

Some individuals with TBI largely move away from the notion of “recovering” the pre-injury self. They reach a point, instead, when they view the losses/changes/deficits as “simple facts” or even “opportunities.” For these people, terms such as “devastation” and “loss” get redefined and no longer are seen as applying to them. Their injury has let them see other possibilities for their lives than what they saw before injury. These possibilities may be just as (or more) satisfying to the person with TBI than what was “in store” for them prior to injury.

When Depression Is The First Sign Of A Brain Tumor

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The 54-year-old patient was physically weaker, had stopped showing interest in her past hobbies and was spending more and more time in bed. She said she was feeling irritable, lacked willpower and blamed herself for not being effective at work. Her husband also mentioned problems with her memory.  

After running lab tests on her and finding no abnormality, her doctors suspected the cause was psychological and prescribed different antidepressants, one after another, when they failed to work. But it turned out that the woman, who at that point had suffered from unexplained, untreatable depression for six months, had several tumors in her brain — especially in the left frontal lobe, which is linked to more depressive symptoms than tumors in the back of the brain. After surgeons removed the growths, her depressive symptoms completely disappeared within a month. The discovery put a stop to her depression and prevented further brain damage, as well as saved her life.

Doctors usually only order brain imaging scans for patients who have neurological symptoms like seizures, vision and hearing loss or cognition problems, but this case is an important reminder thatsometimes a psychiatric illness — in this case, depression — is the only outward sign of a brain tumor, the authors write in thejournal BMJ Case Reports.

© BMJ 2015
MRIs indicating multiple meningiomas in the patient’s brain.

The woman turned out to have Meningiomatosis — a condition in which several tumors, called meningiomas, are present in the brain. Meningiomas can be deadly, with a five-year survival rate of 70 percent. (To put that in perspective, this is worse than breast cancer’s rate is 89 percent.)

To illustrate just how tricky it is to diagnose these benign, asymptomatic tumors, a 2004 study on meningiomas examined 72 cases and found that 21 percent of the patients first sought help because of psychiatric symptoms — most of them related to depression or anxiety. We’ve also known for a long time thatpsychiatric illnesses like anorexia nervosa, depression, anxiety and schizophrenia can also be the only indicators that a mass is growing in the brain.

That said, it’s important to note that depression and anxiety are far more common due to psychological factors.

“It seems unrealistic to prescribe brain imaging in every patient with a depressive syndrome,” the authors wrote in the study. “Indeed, depression is a frequent mental disorder, and brain tumours are remarkably rare in patients with depression.”

But based on this woman’s case, the authors did suggest a few ways to tell whether or not a person with depression should get scanned. If you’re over 50, have never had depressive symptoms before and you’re not responding to antidepressant medication, it may be time to consider a scan.

In this particular case, the woman had experienced several stressful events recently, but had no family or personal history of depression, and didn’t feel guilty or suicidal. In fact, it was this woman’s lack of feeling — apathy to both good or bad news — that the authors say is another sign that a brain scan was warranted.

Major depression is a condition caused by a complex mix of genetic, environmental, chemical and psychological factors. Most people can get treatment for their symptoms by taking antidepressant medication, going to psychotherapy sessions or doing both.

The Weird, Scary and Ingenious Brain of Maria Bamford

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Maria Bamford has a mantra of sorts, and here it is: Do the work. Three words, three syllables. An easy, orderly thing. She tells it to herself when she wakes up in the morning, whether it’s at her bungalow in a middle-class neighborhood on the outskirts of Los Angeles or at a Holiday Inn in Boston or a Marriott in Bloomington, or any of the other highway-side hotels she hits for one night before moving on. Do the work. It’s a stay against paralysis, against the descent of dread. It’s less dramatic than “seize the day!” more affirming than “stop overthinking everything!” It is functional, and that’s what she’s trying to be. Do the work. She repeats it on airplanes, in taxis, on the long walks she takes to calm her nerves before a show. Sometimes she amends it to: Just do the work, the “just” a reminder that she’s not, after all, performing surgery on babies. There’s another, more refined version, too. Do your bits, she’ll tell herself, resigned to the idea that this may always be a struggle. Just do your bits.

It should be simple, even if it’s not. Because she’s a comedian, and comedians do bits.

The first time I met Bamford, one evening in May, she was at a theater in Boston, about to step in front of an audience of roughly 600 people. She had been rehearsing her bits all afternoon, silently delivering jokes as she speed-walked alone along the Charles River, internally running through the intricacies of her timing as she browsed a couple of bookstores in Cambridge, thinking up a few chummy Boston references she could throw in to her 60-minute monologue. Now, dressed in black pants and a quilted North Face pullover, Bamford paced a small room backstage, her layered blond hair mussed and a little spiky, her blue eyes downcast as she avoided chitchat. What she was feeling, she’d later tell me, was “terror.”

You would think that stage fright, at this point in her career, wouldn’t be an issue. Bamford is 43. She has been doing stand-up comedy since her early 20s, when she was living in Minneapolis, a two-hour drive from her childhood home in Duluth. She has put out three well-received albums, twice done sets on “The Tonight Show,” landed a guest role on the third season of “Louie” and has had two half-hour specials on Comedy Central. Judd Apatow has described her as “the most unique, bizarre, imaginative comedian out there right now.” Last year, she appeared in the Netflix revival of “Arrested Development,” stealing scenes as DeBrie Bardeaux, a freakish, endearing meth addict in recovery. Mitchell Hurwitz, the show’s creator, calls Bamford “a genius” and “a real artist.” He adds, “Real artists talk about things that nobody else talks about, and talk about them candidly.”

Things Bamford likes to talk about candidly include the fact that she has disabling bouts of anxiety and depression, that she has contended with a form of O.C.D. called “unwanted thoughts syndrome” and that during her childhood, those unwanted thoughts came in the form of constant worries she might kill her own family or sexually molest animals. And while her comedy routinely traverses more everyday subject matter — she mimics her stalwart Minnesotan parents with devastating precision; she deftly does bits about emojis, online dating and her deep lack of interest in cooking — all of it seems anchored, one way or another, in Bamford’s psychological fragility. When she does her stand-up, when she acts on television and most notably in several web series she has written and starred in, she plays an exaggerated version of herself — a tremolo-voiced woman with a stunned expression, trying to navigate a world of people whose confidence is appreciably higher than her own.

In her work, she describes having done stints at inpatient psychiatric units and also the diagnosis she received a few years ago of Type-II Bipolar, an increasingly recognized variant of bipolar disorder. (“It’s the new gladiator sandal!” she will declare onstage.) Narrating the particulars of her psychology, which also include a history of binge-eating and having suicidal thoughts, Bamford displays little in the way of anguish and nothing resembling self-pity. She appears before audiences simply as vulnerable, as someone whose ongoing presence in the world is not entirely assured. She likens herself in temperament to a daffodil or an orchid, capable of wilting if the conditions aren’t perfect.

In Boston that night, she stood in the shadows at the edge of the curtain, watching a local comic, a tall woman with a swaying Afro, perform a warm-up set for the waiting crowd. Every time the other comedian delivered a joke, Bamford guffawed loudly from the wings, an odd, overdone warble that split the darkness, offering encouragement to the lesser-known act. Comedy, like most businesses, is baldly hierarchical. Bamford herself is only midway up the ladder, a headliner but not a superstar. She wants more, but then again she doesn’t. Just do the work.

The audience was now applauding. It was her turn to go on. Her jitters revved, as they always do. Smiling almost sheepishly, she began the 15-foot walk across the empty stage, toward the puddle of light with a microphone at its center. She looked, in that moment, like a woman who would either crumble or roar.

The minute Bamford lifted the microphone, her nervousness morphed into something more potent and focused. She began with some lighter material about making a ceramic dog for her father and a Vine video she could play anytime someone complained she wasn’t good at expressing her emotions. (She acted it out onstage in jerky, six-second bursts: “I love you . . . O.K.? I love you . . . O.K.?”) From there, she ran through an exuberant and juvenile riff on farting, including a lot of vivid sound effects, and then eventually she rounded the corner, as she almost always does, to talking about suicide. (“Is anyone thinking of suicide?” she asked the crowd, sounding merry. “Well, don’t do it, it’s not the season for it.” She then crinkled her face into a childish pout. “And people will be so mad at youif you do that.”)

Much of Bamford’s work examines the relationship between “people” — generally well-intentioned friends and family — and those who grapple with depression or anxiety or any other challenge to the psyche. Her act is a series of monologues and mini-skits performed rapid fire and often without regard for transition. Deploying a range of deadpan voices, she mimics the faux-enlightened who hover around the afflicted, offering toothless platitudes (“You just need to get out in nature”), bootstrapping pep talks (“It’s all about attitude. You gotta want it!”) or concern warped by self-interest (“You’d think you’d just stop vomiting for me and the kids”). The humor of any given moment relies not so much on punch lines as it does on the impeccably timed swerves of her tone, the interplay between Bamford’s persona and those of all the people who don’t get her. Often, she is demonstrating helplessness on both sides. “We love you, Maria,” Bamford says, imitating her 69-year-old Midwestern mother, Marilyn, in one of her recorded performances, heaving a fed-up sigh. “We love you, we love you, but it’s hard to be around you.”

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Bamford is a small person, narrow-shouldered and spindly legged. Her speaking voice is also small and a bit quavery, lending a charming uncertainty to anything she says. Wrapped inside the wobbliness, though, is an earned authority. Bamford talks about mental illness the same way Sarah Silverman talks about being Jewish or Louis C.K. talks about being divorced, with the flippant knowingness of an insider. Occasionally, the sharper pieces of her agenda poke through. One of her more jarring bits is about war veterans. She points out that more than 7,000 U.S. veterans die of suicide every year. “Which is funny,” she says, breaking into a giggle as a predictable hush falls over the room, “Because you’d think they’d die over there, but they come home. . . . ” The audience quickly explodes into laughter — not because it’s funny, but because it’s funny coming from her.

After the show, a crowd lingered late in front of the theater, waiting to speak with Bamford. She is frequently approached by people who view themselves as part of her tribe, who want to talk about their own diagnoses and tell their own tales of being misunderstood. In making light of the hidden struggles and deep absurdity that accompany living with, or close to someone with, mental illness, she appears to have planted an appealingly honest flag. She gets mothers who say, “I have a daughter just like you,” and daughters who say, “I have a mother just like yours.” She gets people — a lot of people — who say that her frank talk about suicide has made a difference to them personally.

The next morning, Bamford climbed into my car, holding a takeout salad she’d brought from the hotel, an early lunch for the ride ahead. We were going to Albany, about 160 miles away, where that evening she was due to put on another show. Ticket sales, she’d heard, had been slow. As it is with many comics, the specter of bombing always loomed. “I don’t know,” she said as we pulled onto the Interstate. “You may see it tonight.”

I told her I thought the Boston performance was great, but she waved off the compliment.

“It was good,” she said. “I mean, yes . . . , but I was slightly disappointed with myself.”

When I asked why, she fumbled for words. “Just psychologically . . . ,” she began, and then trailed off.

Close up, Bamford is milder than she is onstage. She has a thoughtful and friendly demeanor, but it’s edged with a certain nervousness. The verbal acrobatics that pump energy into her monologues, you soon realize, are not flashes of spontaneous genius but rather the product of huge amounts of time spent in focused rehearsal. (When she’s developing new material, she will pay friends $75 an hour to listen to her practicing bits over the phone.) In casual conversation, words come less easily. Bamford often appears to rethink her sentences midway, leaving many of them unfinished. Some of this may be attributable to Depakote, the mood stabilizer she takes daily. It’s one of a number of concessions she has made in the name of stability. Thanks to the medicine, she also now needs at least 10 hours of sleep each night, she says, “and also another hour to nap.”

When it comes to stage fright, Bamford laments that there seems to be no remedy. She enjoys performing, but only after the fact. Even just thinking about doing stand-up that night made her panicky. “I think I’m going to start working with a coach,” she added. “Just to get some daily support.”

She is, if anything, a dutiful seeker of help. One night in 1990, when she was a sophomore at Bates College in Maine, experiencing a period of despair, she wolfed down a huge amount of food and then called a suicide help line. Ever since, she has maintained faith in support networks. She has participated in 12-step programs for eating disorders, money problems, sex and intimacy struggles and addiction, though substance abuse has not been an issue for her. She just appreciates the company, and also the honesty. “I think 12-step programs are genuinely cognitive behavioral programs,” she told me. “You are out of isolation, and that helps you think differently about things.” When traveling, Bamford looks for local support-group meetings to visit. Otherwise, she attends them by phone. She has found a sense of community in online chat rooms and is a vocal fan of Crazymeds.us, a website that gives advice about psychiatric medications. (In addition to the Depakote, she also takes Prozac for depression and occasionally beta blockers to calm a tremor in her hands.)

She sometimes talks about her brain as an entity not entirely in her command, as something unruly and perhaps best understood from a slight distance. “My brain wanted me to think,” she will say, describing unhealthy perceptions, or “My brain wasn’t doing so great,” recalling a darker time. Her brain, she has found, behaves best in controlled settings, thriving on rules and boundaries. Twelve-step programs are good this way. And so, too, curiously enough, is stand-up comedy, stage fright notwithstanding. When at one point I remarked that putting yourself alone onstage before a judgmental audience seemed like a punishing thing to do, Bamford said: “Yes, but for me it’s also a structured environment, and structured environments feel safe. I’m up there in the lights, saying what I want to say, and they’re sitting a safe distance away.”

Most everyone I spoke to about Bamford felt compelled to mention that she’s a deep thinker, an observant introvert who processes everything carefully. “She’s always churning the butter,” was how her older sister, Sarah Seidelmann, put it.

“You know what it’s like?” says Jackie Kashian, a comedian who has known Bamford for about 20 years and sometimes travels with her as an opening act. “It’s like being best friends with Hermione Granger. You spend a lot of time in the library.”

And it’s true. Bamford normally hauls a bag of books and magazines with her when she travels, never knowing where she might find a steadying revelation. She’s a lover of recovery memoirs, psychology tomes and bullet-pointed self-help manuals. She can quote liberally from “The Artist’s Way,” by Julia Cameron. She reads O.C.D. books with titles like “Tormenting Thoughts and Secret Rituals.” She also plows through People magazine as well as lots of highbrow literary writing and is, in particular, a fan of Dave Eggers. (“I sometimes put my name next to his,” she confides in a 2011 video she posted online about books she loves. “Like, what would it be like to be Mrs. Eggers?”)

She is bolstered, she says, by hard facts. A subscriber to AARP Magazine, she enjoys citing studies about health and longevity. A few years ago, after reading in a book that people who feel a strong sense of community have been proven to lead longer and happier lives, Bamford started working to overcome her natural shyness and fear of interaction by saying hello to her neighbors in Eagle Rock, a diverse and partly gentrified area on the northeastern edge of Los Angeles. She bought a park bench and had it installed on the median strip in front of her house. She then spray-stenciled the words “Have a Seat!” on the sidewalk in front of it. To her delight, the bench is often occupied. “It’s like a bird feeder for humans,” she says.

In the car that day, Bamford told me she was reading something called “The Procrastinator’s Handbook,” which was all about overcoming anxiety and just doing the work. She told a story about how a couple of years ago, when she was feeling leveled by depression and anxiety, a mutual friend connected her with the comedian Jonathan Winters, who was at that point well into his 80s. (He died last year.) Like Bamford, Winters was a gifted mimic, known for creating satirical characters. He also suffered breakdowns, spent time as a patient in psych hospitals and as early as the 1960s was hinting at his psychological struggles in his comedy routines. Eventually, too, he was given a diagnosis of bipolar disorder. Bamford recalls that when she spoke to Winters on the phone, she was just out of the hospital herself and deeply scared about continuing on with both comedy and life. Winters, she says, offered what turned out to be a useful bit of blunt-force wisdom. “He said: ‘You got a good shrink? Yes? Well then, you just keep going.’ ”

Bamford has a song that she sometimes performs onstage called “My Anxiety Song.” It has no melody. Instead, it sounds more like an incantation, a desperate verbal hum. “If I keep the ice-cube trays filled,” she chants, “no one will diiiiieeee.” She continues, in a monotone, “As long as I clench my fists at odd intervals, then the darkness within me won’t force me to do anything inappropriate or sexual” — here, she drops her voice a couple of notes — “at dinner partieeeees. . . . “

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This, she is saying, is the agony of O.C.D., the skewed sense of cause and effect that first began to plague her when she was about 10. According to the National Institutes of Health, about 2.2 million adult Americans contend with some form of obsessive-compulsive disorder. It’s not uncommon for the symptoms to appear during childhood. Bamford is patient when explaining the particulars, aware that when she jokes about having wanted to chop up her family into bits or imagining what it would be like to lick a urinal, it can make her sound weird and also scary. But she makes a distinction: It’s the thoughts that are weird and scary, not the person. And while most of us are prone to having fleeting notions that would qualify as inappropriate, in the mind of someone with O.C.D., they are more likely to lodge themselves and repeat. The thoughts don’t tend to inspire action, only fear. It’s like having a homegrown terrorist in the brain.

During her childhood, the thoughts kept her from sleeping. As her anxieties combined with exhaustion, she began to isolate herself, contemplating suicide as early as middle school. At some point, she shared her fears with her mother. The whole family — Bamford, her parents and her sister — went to counseling for a while, with mixed results. “We weren’t in the golden age of psychotherapy in Duluth,” recalls Marilyn Bamford, who was then a stay-at-home-mother but later became a family therapist herself. Maria remembers going to the therapist and “mostly just taking naps on her couch, because I was so tired, and it felt like a safe place.”

Her compulsion for violent thoughts felt so shocking that she was afraid to share them, even in therapy. She finished two years of college in Maine and another year at the University of Edinburgh in Scotland — feeling “supercompulsive and superdepressed the whole time” — before transferring to the University of Minnesota, where she majored in creative writing. At 22, she was prescribed antidepressants, which helped only somewhat.

Throughout it all, she was drawn to performing. As a child, Bamford showed talent as a violinist. She acted and sang in school plays. In her early 20s, she shaved off all her hair and moved into a feminist housing collective in Minneapolis, holding down a job at a pizza place while doing what she calls “hippie performance art” in coffee shops and black-box theaters, mixing violin-playing into her act. To earn extra money, she busked on the street with the violin. “I was really just trying to express myself,” she says. Being a baldheaded woman, she sees now, was an unconscious ploy to ward off intimacy and keep her struggles hidden: “People are like, ‘Oh, you’re a weirdo, I’ll stay away.’ ”

During this period, Bamford met Jackie Kashian, who performed at open-mike shows in Minneapolis, where Bamford would sometimes surface, thin and hairless and carrying her violin. “Her material was always sideways,” Kashian remembers. “She wasn’t examining the same topics a lot of other people were examining. It wasn’t going to be: ‘Hey! Airline food!’ or, ‘How am I gonna date more?’ It was usually like, ‘There’s this weird thing happening in Sudan.’ ” Club owners often perceived Bamford as “too smart for the room,” she says, adding, “Sometimes that’s just a polite way of saying ‘I don’t get you.’ ”

It wasn’t until she was in her mid-30s, after moving to Los Angeles, that Bamford finally found an O.C.D. specialist who was able to treat her unwanted thoughts using a technique called “flooding.” She was instructed to write down her compulsive fears in exacting detail, then to record herself reading them out loud and, finally, to play them back for herself, again and again, until they stopped causing her anxiety. Most of her fears were about harming other people or forcing herself on someone sexually. She recalls the flooding exercise as “horrifying and painful,” but potent in what it accomplished. While she continues to contend with other psychological challenges, the unwanted thoughts, she says, still sounding amazed, “just went away.”

Over time, too, Bamford has managed to build a stronger bridge between herself and her audiences, largely through truthful self-disclosure. She talks about wanting to commit suicide, calling it a “[expletive] idea,” one of her many stupid thoughts, like buying day-old raisin bread in bulk and freezing it. “My experience is so embarrassing,” she says. “But I’ve learned that it’s O.K. to be yourself. . . . It’s better than pretending that it’s not there.”

Bamford understands that her condition is most likely steered by genetics, or as she sometimes phrases it onstage, “Mentals run in the family.” “My great-grandmother lived her whole life in an attic,” she told me. “Maybe there were other reasons, but my mom seems to think, from her letters and stuff, that she was massively depressed.” Her father, a retired dermatologist, has also cycled through periods of depression. And in 2010, Marilyn Bamford landed briefly in the psychiatric ward of a Duluth hospital, having gone off Depakote, which she’d taken for decades to combat seizures (it’s prescribed for epilepsy and bipolar conditions), and started showing signs of mania. “She was calling the pope and emailing my manager, telling him I was in danger,” Bamford says. “It’s really scary to see someone you know change so quickly like that.”

Her mother’s hospitalization seemed to confirm something Bamford had long suspected about herself, that despite the fact she was now a reasonably well functioning adult with what was starting to look like a sustainable show-business career, there remained a lingering capacity for meltdown. Any gathering clouds were not to be ignored. “I said to my friends, if I ever start talking too fast, please just take me to the hospital,” she said. She had even done a kind of comic rehearsal for it, filming a 2007 web series called “The Maria Bamford Show,” in which a depressed comedian named Maria Bamford — played by Bamford — has a nervous breakdown and moves home to Duluth, tended to by her parents (also played by Bamford), who come off as bumbling, endearingly idiosyncratic and unwittingly critical. The series is hilarious and unusual, and it boosted her cult following.

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In 2011, things were going well professionally. Bamford was getting regular voice-over work on television. She had starred in a popular series of preholiday ads for Target, playing an overhyped shopper. She was booking stand-up gigs as far away as Australia and playing larger and larger venues in the U.S. But her mind, as she puts it, had become like “an untethered jackhammer.” Her energy soared and crashed. After one of her two dogs, a pug named Blossom, took a tumble off her back porch and died — something for which Bamford blames herself, having removed a ramp connecting the porch to the yard — her mood went permanently black. “I could not find any comfort at all — just nothing, and for months,” she says. “I felt terrible, and my brain felt terrible. In the past, I’d always been able to be like, ‘Oh, I’ll write in my journal or read my self-help book, or I’ll call people and get out of this mood,’ ” she says. “But it wasn’t a mood. It was like, ‘Yeah, I’m gone.’ ”

Over the course of about 18 months, she was hospitalized on three occasions, for periods ranging from three to seven days, each time checking herself into the psych ward of a different L.A.-area hospital. “I thought it was the responsible thing to do,” Bamford says now. The hospital stays were in part a way to switch her medications under supervision (she received a Bipolar II diagnosis during her first admission), and in part meant to keep her from committing suicide, which she says had gone from being a vague idea to something that felt like a foregone conclusion, a rational next step.

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A family photo from 1984. CreditFrom the Bamford Family

Bamford’s sister, Sarah Seidelmann, visited her at Glendale Adventist hospital and says she felt taken aback by the number of patients who seemed lost in schizophrenia or were practically catatonic with depression. “I remember thinking, Oh, my gosh, all these people look terribly dispirited,” Seidelmann says. “These aren’t the people who can help you get better!” Seidelmann, who lives in Minnesota with her husband and four children, is a certified life coach. Her website asks, “Are You Ready for an Absurdly Fantastic Life?” She is also a recurring character in her sister’s stand-up routine, depicted as a hyperalert, finger-chewing realist who sees every problem as innately solvable and who often aggressively tries to redirect her sister’s negative thoughts. (In one skit, when Bamford says, “I’m worried I’m too old to be in show business,” the stage version of Seidelmann spits out an instant dismissal: “Hmmm. Betty White, Dame Judi Dench, Joan Rivers. . . . You’re not old enough!”)

According to Seidelmann, Bamford’s imitations of the family and their various blunders are biting in ways that can be painful — “My father cried, the first time he saw her doing him onstage,” she says — but they can be illuminating, not just inside the family but also inside a world rife with struggling people. Bamford’s comedy swims with paradox. She skewers the culture of self-improvement but relies on it, too. She pokes fun at the people who blithely misunderstand her, but also credits them for giving her love and shelter. (“You’re horrible,” she thinks about a friend who visits her in the psych ward and says all the wrong things. “But can you come back tomorrow?”) She addresses the loneliest of gulfs, acknowledging the confounding intimacies of living with and in proximity to mental illness — the whipsawing, humbling forbearance required from everyone involved.

Seidelmann, when I talked to her on the phone, got choked up, recalling seeing her sister pale and quiet and surrounded by a lot of hard-luck cases in the linoleum-floored psych ward in 2011. “My first instinct was to say, ‘Dude let’s get you out of this place,’ ” she says. “But Maria was trying to tell me something different. She was saying, ‘I feel safer here than I do at home.’ ”

Last month, I went to a meeting with Bamford in Los Angeles. It wasn’t a support-group meeting, but rather a business meeting, at a sprawling Beverly Hills office complex that’s rapidly being taken over by Netflix. As the company grows, there could be opportunity for someone like Maria Bamford, whose sensibilities don’t readily bend to those of network television but whose appeal with certain, quirk-loving audiences is well established. For the last few months, Bamford had been talking with Mitchell Hurwitz, the “Arrested Development” creator — a comic maverick in his own right — who had recently signed a development deal with Netflix, which came with an office and a mandate to launch new series.

“We’ve been drinking bottled water and eating salads and thinking out loud,” Bamford told me. “It’s how things get done in L.A.” She was dressed that day in jeans and a blue-green blouse, and when we met, in the sunshine outside the Netflix headquarters, she also wore an enormous wide-brimmed black hat. Something about it, the big, drooping hat sitting atop her thin-stemmed body, reminded me of how she likened herself sometimes to a flower, how vulnerability and resilience can coexist.

These days, Bamford credits the Depakote with keeping her stable. She sees a therapist weekly and a psychiatrist every three months. She no longer feels suicidal and remarks on that often — “It’s incredible!” she says — as if she has finally, after 33 years, shaken a persistent head cold. Following the hospitalizations, she says, it took almost eight months before she felt well enough to work at anything resembling a regular pace.

There’s a sweetness attached to her newfound balance: Bamford is in her first sustained romantic relationship, with an artist named Scott Marvel Cassidy, whom she met in early 2013 on OkCupid.com, advertising herself under the user name Hogbook. (“I used to have a profile that suggested I was fun-loving and happy,” she says. “But Hogbook felt more honest.”)

When Bamford and I walked into Hurwitz’s office that day, he embraced her warmly. Hurwitz is effusive and has a quick-moving wit. The show they were discussing would be based roughly on Bamford’s life experiences, including, possibly, her stays in the psych ward. “I guess what I want to do is make mental illness feel more normal, more like a regular thing,” Bamford said. The question was how to develop the central character and give her a compelling narrative arc. Hurwitz mentioned that a few nights earlier he sent an email to Bamford, wondering what the Maria character’s trajectory should be. “What’s she aiming at?” he wanted to know. To which Bamford replied, only partly joking, “Maria don’t do trajectories.”

Conversations about ambition, especially since her hospitalizations, cause her to blanch. She has cut back on her travel, doing only a couple of shows on the road per month. She continues to do voice-over work and has had some small television parts, but she no longer goes to auditions, understanding that her oddball style is unlikely to land her any conventional roles. When she does things now, they are very much on her own terms. Her latest special — called “The Special Special Special!” which she made available for download late in 2012 — was released in May on Netflix. Rather than filming a live theater performance, as most comics do, she chose to stage her act in the comfort of her own living room in Eagle Rock. Lit by amateurish spotlights and with a keyboardist playing music during transitions, Bamford delivers a rollicking 45-minute set to an audience of two — her parents — who sit on her sofa, trying to look appreciative, clapping and laughing even as she mimics them. It makes for a weirder and funnier show and also, as her comedy often does, makes a subtler point about the burden families bear.

Critics have called Bamford’s special “hilarious,” “fearless” and “brilliant.” Riding alongside the compliments is a perceptible whiff of anticipation, a sense that she’s sitting on the edge of bigger things. The question of how hard to push herself, however, openly perplexes her. In our conversations, she fretted over whether it was O.K. to be a marginally productive comic, wondering if, in dialing back her time on the road, for example, she was being self-protective or just lazy. “I look at people who are hustling,” she said on the day we drove to Albany. “They’re working their butts off and doing a great job, and I don’t know if I’m ever going to be that person. I mean, I think there’s a reason I’m not famous.”

Bamford even has a bit about her productivity in her routine: “People want to know: ‘So what are you working on? What’s going on with you? What’s the next page? What’s coming up for you? What’s on the horizon?’ ” she says, adopting the fatuous voice of someone making small talk. “And I say: ‘Oh. I’m done. . . . Yeah, I finished early. I’m actually living in a gravy boat filled with delicious gravy.’ ”

I got to see her do that bit in May after we finally reached Albany that night. Bamford had worried about ticket sales, but the house was full. She’d worried that the comic opening for her, an energetic young New Yorker named Joyelle Nicole Johnson, wouldn’t make it to the theater on time, but she did. Twenty minutes before the show, Bamford sat on a worn couch in the greenroom with her legs crossed, anxiously reading her copy of “The Procrastinator’s Handbook,” which was filled with sentences she’d underlined in ballpoint and drawn big stars next to in the margins. Soon, the stage manager would come to get her and the house lights would dim. Soon, she’d be out there, making her case for the mentals and hearing people laugh in recognition. They always did. Earlier, in describing the stage fright, she told me that she knew that performing wasn’t exactly a life-or-death thing. But somehow, it still felt like an exercise in overcoming.

Newborn twin died from massive brain injury just 24 hours after doctor ‘pulled him around like a rag doll during bungled delivery’

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A newborn twin died from a massive brain injury just 24 hours after a doctor pulled him around ‘like a ragdoll’ during a bungled delivery, a medical tribunal heard.

Harry Page, who was upside down in his mother’s womb in a breech position, was pulled by his feet with such force by Dr Anupama Ram Mohan his father feared his neck would snap, it was claimed at a medical tribunal in Manchester.

Harry was eventually delivered by Mohan – who was said to be ‘gritting her teeth – but the infant had already suffered injuries to the base of his skull causing traumatic hemorrhaging, and he died the following day.

Harry Page, who was upside down in his mother Vicki's womb in a breech position, was pulled by his feet with such force by Dr Anupama Ram Mohan his father Owen (pictured with Mrs Page) feared his neck would snap

Harry Page, who was upside down in his mother Vicki’s womb in a breech position, was pulled by his feet with such force by Dr Anupama Ram Mohan his father Owen (pictured with Mrs Page) feared his neck would snap

Dr Mohan, pictured, is accused of inappropriately delivering Harry, who died less than one day later

Dr Mohan, pictured, is accused of inappropriately delivering Harry, who died less than one day later

Dr Mohan, who trained in India before working in Oman, had only been at the John Radcliffe for four months and was working as a specialist trainee registrar in obstetrics and gynaecology. She was later accused of lying at an inquest into the tragedy.

The Medical Practitioners Tribunal Service was told the incident occurred in 2012 after Harry’s mother Vicki was taken to the Oxford hospital to have Harry and twin brother Ollie induced.

Ollie was born safely at 1am on December 15, with Harry following shortly afterwards. His legs and body were delivered easily but Mohan encountered difficulties when trying to release his head.

Harry’s father Owen, 51, a warehouse manager, told the tribunal he became concerned when midwife Jane Bruce asked Dr Mohan, ‘why are you rushing this?’.

Mr Page, of Aylesbury, Buckinghamshire, said: ‘Harry was being pulled round like a ragdoll. It appeared she was pulling him side-to-side and up and down.

‘His legs were almost touching my wife’s stomach…. It appeared to me at the time that Dr Mohan was gritting her teeth to do this procedure, she had a really tight face.

‘Watching the movement and the force and the look on her face worried me. I thought it was an uncontrolled procedure. She then let him hang there with no support for a period of time before she did the same procedure again.. She was standing there with her hands down by her waist. On the second manoeuvre he literally popped out.

‘Initially I thought Harry’s neck was going to stretch, break or give in. I was horrified by it. It looked like it was so stretched it was going to snap.’

HR director Mrs Page, 35, added: ‘I felt it was aggressive when I was there and I was looking at others for reassurance and didn’t get that when I looked at people’s faces so I was concerned.’

At 4am Harry was rushed to the resuscitation unit when his condition quickly deteriorated. By 2am on December 16 he was dead, with later examinations revealing he had suffered a massive brain injury while being born.

Mrs Page said: ‘I believe the manoeuvre she carried out caused his death and it was irreversible as the consultant told us on the day we turned his life support machine off.’

The hearing was told Mohan had tried two different procedures to deliver Harry – the Burns Marshall and the Mauriceau Smellie Veit. She initially tried the Burns Marshall method then the MSV before returning to the original procedure.

General Medical Council lawyer Paul Raudnitz said: ‘Dr Mohan performed the Burns Marshall but did so in such a way she brought the legs of Harry greater than the vertical and near to Mrs Page’s abdomen.

‘She has accepted she attempted a Burns Marshall, but denied it was with any force and, in particular, she has consistently denied that she brought the legs greater than the vertical. She has said she went on to perform MSV and maintained that that was successful in delivery.

‘She has denied there was any attempted, successful or otherwise, second Burns Marshall. Whether she brought the legs greater than the vertical in one or more of the Burns Marshall manoeuvres the GMC say the way she performed is part of the issue.

‘Should it be found she brought the legs greater than the vertical then we would say that the standard of care was seriously below that expected of a reasonably competent registrar in obstetrics.’

Mr Raudnitz added that Dr Mohan, 51, of Milton Keynes, then gave ‘false evidence’ to the coroner in 2013 to ‘minimise her culpability for what happened’.

Mohan denies misconduct and denies causing Harry’s death. She is also accused of failing to record issues she encountered during Harry’s birth but admits failing to record using one or more Burns-Marshall manoeuvre. She denies advising for inappropriate medication to be administered during the delivery, making false records and giving false evidence to the inquest.

Miss America Contestant Is a Voice for Traumatic Brain Injury

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I had the pleasure of chatting with Ali Wallace, currently Miss Oregon. Early September she will head to Atlantic City to compete in the Miss America Pageant. Ali is a beautiful, smart, young woman who also happens to have an invisible injury that she struggles with every day — a traumatic brain injury (TBI).

In her freshman year of high school, she made the varsity Cheer team. This was a very distinct honor not given to many freshmen. She felt a bit of pressure to keep up with the other girls on her team and would practice her tumbling skills outside of practice.

One afternoon, she was at the dance studio working on her round-off back tuck. She wasn’t comfortable with this move yet, and she became nervous in the middle of her flip, resulting in her falling to the floor. She landed half on the mat and half on the hardwood floor, with the back of her head/upper neck hitting first. Her mom saw it happen and rushed over to assist her.

Ali immediately knew that something wasn’t quite right.

She had completely lost vision in her left eye, and had decreased vision in her right. She was seeing stars and feeling woozy. Her mom called the nurse line to see if they should bring her in to see a doctor, and was assured that she should be fine-and to just go home and rest. In fact, Mom was told not to bother bringing Ali in to the clinic.

Her accident occurred in 2009, a time when concussions were “no big deal,” a time when athletes were sent back on the field to play, and a time when doctors didn’t understand that there might be long-term lasting effects. Even today, many people can misunderstand concussions, including medical professionals.

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While awareness is growing as NFL players come forward and tell their stories, this isn’t enough. When the average person hears the word “concussion,” he or she might think it’s no big deal. When people hear the words “traumatic brain injury,” they imagine the worst-case scenarios -people who are in a coma or confined to a wheelchair. This simply isn’t the case, as one can see while looking at Miss Oregon.

More survivors of concussions need to step forward and shed light on the issue, which is exactly what Ali is doing. She is using her platform at the Miss America competition to bring a face and a voice to this debilitating injury.

The day after her accident, Ali’s entire body ached all over. Light hurt her eyes, sounds made her head throb, it hurt to read, and she was feeling dizzy and nauseous. Her mom once again called the nurse line, and finally Ali was instructed to go see her doctor.

As soon as her primary doctor saw her, he knew something wasn’t right. He ordered a brain scan, which showed some minor bleeding on her brain. While it didn’t require surgery, Ali was told she had suffered a traumatic brain injury. She was instructed to take an entire month off of school to rest and recover.

Ali said, “When I took a month off of school, there was a combination of jealousy, and those who thought I was just trying to get out of going to school. You can’t see a concussion, it’s not like a broken arm where you can see it’s broken.”

At her follow-up appointment, she wasn’t able to see her regular doctor. This doctor now told her “If you can put on your makeup, then you are fine.” His statement stunned both Ali and her mom.

Sadly, this is an all-too-often generalization: If you look fine, can talk and walk, then you must be okay. It is extremely frustrating to survivors, and can be quite disheartening.

Ali continued with her follow-up appointments, seeing her regular doctor. She was still feeling dizzy and nauseous, and was told that it could take about a year to get back to feeling normal. While her friends were out having fun, she spent her entire summer break resting in a dark, quiet room, trying to give her brain adequate time to heal and recover.

“You’re brain controls your entire body. If your brain is injured, things don’t work correctly,” Ali commented.

After missing an entire year of Cheer, her doctor cleared her to return. Ali shared that mentally she was never able to do tumbles again, as she always had a small fear in the pit of her stomach. She didn’t want to risk another bad landing and injure herself further. Regardless of her fears, she put her best effort into Cheer, and continued to thrive during her last two years of high school.

Six years later, Ali continues to struggle with the after-effects of her TBI.

She has frequent headaches, and she lacks depth perception in her left eye, which causes her to sometimes run into doorways or other objects that are on her left side. She has a lot of balance issues, which has put a damper on her dancing. She struggles with aphasia (being able to recall words), and has mastered the art of redirecting her sentence, using a different word. She also gets lost while driving, often having to pull over and try to figure out where she was headed by looking at her calendar.

Her biggest fear in the Miss America competition is being perceived as not being intelligent, especially when she can’t come up with a word quickly enough. “It’s embarrassing to be stuck in the middle of a sentence and not be able to think of the right word.”

Those who have never struggled with a TBI have no idea how frustrating aphasia can be, and outsiders who see a very pretty face sometimes make unfair assumptions and judgments.

Ali uses lots of lists to cope with her memory problems, spending time each night before bed writing down what she needs to do the next day. She continues to have sensitivity to light and sound, and struggles to remember people’s names. Overall she is doing great, and will be attending Portland State next summer to finish her BA degree. She plans to pursue a Masters of Film degree from the University of Southern California.

When she picked talking about TBI as her platform, she wanted to bring awareness to a topic that nobody is talking about. She has personal, first-hand experience with it, and is a cause that she wants to continue to shed light on and support.

Her biggest message she wants to bring the world is this: “I want people to understand how serious TBI is. When the conversations of brain injuries come up, I want it to be general knowledge of how serious and complex the injury is. No two brains heal alike, and it’s not like a bone where the standard recovery time is 4-6 weeks. The minimum recovery time for a very mild concussion is three months. Unfortunately, there is no formula to know when you’ll recover or heal.”

Types and Levels of Brain Injury

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Types of Brain Injury

All brain injuries are unique.  The brain can receive several different types of injuries depending on the type of force and amount of force that impacts the head. The type of injury the brain receives may affect just one functional area of the brain, various areas, or all areas of the brain.

Traumatic Brain Injury  •  Acquired Brain Injury • Levels of Brain Injury


Traumatic Brain Injury

Concussion

Even a concussion can cause substantial difficulties or impairments that can last a lifetime. Whiplash can result in the same difficulties as head injury. Such impairments can be helped by rehabilitation, however many individuals are released from treatment without referrals to brain injury rehabilitation, or guidance of any sort.

  • A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.
  • Both closed and open head injuries can produce a concussion. A concussion is the most common type of traumatic brain injury.
  • A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged.
  • A person may or may not experience a brief loss of consciousness.
  • A person may remain conscious, but feel dazed.
  • A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan.
  • Skull fracture, brain bleeding, or swelling may or may not be present. Therefore, concussion is sometimes defined by exclusion and is considered a complex neurobehavioral syndrome.
  • A concussion can cause diffuse axonal type injury resulting in temporary or permanent damage.
  • A blood clot in the brain can occur occasionally and be fatal.
  • It may take a few months to a few years for a concussion to heal.

Contusion

  • A contusion can be the result of a direct impact to the head.
  • A contusion is a bruise (bleeding) on the brain.
  • Large contusions may need to be surgically removed.

Coup-Contrecoup

  • Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.
  • This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion.

Diffuse Axonal

  • A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident.
  • Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.
  • There is extensive tearing of nerve tissue throughout the brain. This can cause brain chemicals to be released, causing additional injury.
  • The tearing of the nerve tissue disrupts the brain’s regular communication and chemical processes.
  • This disturbance in the brain can produce temporary or permanent widespread brain damage, coma, or death.
  • A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.

Penetration

Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bones and fragments from the object into the brain.

  • Objects traveling at a low rate of speed through the skull and brain can ricochet within the skull, which widens the area of damage.
  • A “through-and-through” injury occurs if an object enters the skull, goes through the brain, and exits the skull. Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue. (Brumback R. (1996). Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd Ed.). New York: Springer.)
  • The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall. (Center for Disease Control.

Acquired Brain Injury

Acquired Brain Injury, (ABI), results from damage to the brain caused by strokes, tumors, anoxia, hypoxia, toxins, degenerative diseases, near drowning and/or other conditions not necessarily caused by an external force.

Anoxia

Anoxic Brain Injury occurs when the brain does not receive any oxygen. Cells in the brain need oxygen to survive and function.

Types of Anoxic Brain Injury

  • Anoxic Anoxia- Brain injury from no oxygen supplied to the brain
  • Anemic Anoxia- Brain injury from blood that does not carry enough oxygen
  • Toxic Anoxia- Brain injury from toxins or metabolites that block oxygen in the blood from being used Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor

Hypoxic

A Hypoxic Brain Injury results when the brain receives some, but not enough oxygen.

Types of Hypoxic Brain Injury

  • Hypoxic Ischemic Brain Injury, also called Stagnant Hypoxia or Ischemic Insult- Brain injury occurs because of a lack of blood flow to the brain because of a critical reduction in blood flow or blood pressure.

Resources:

Brain Injury Association of America, Causes of Brain Injury. www.biausa.org

Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor


Levels of Brain Injury Brain Injury

Mild Traumatic Brain Injury (Glasgow Coma Scale score 13-15)

Mild traumatic brain injury occurs when:

  • Loss of consciousness is very brief, usually a few seconds or minutes
  • Loss of consciousness does not have to occur—the person may be dazed or confused
  • Testing or scans of the brain may appear normal
  • A mild traumatic brain injury is diagnosed only when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion

Moderate Traumatic Brain Injury (Glasgow Coma Scale core 9-12)

Most brain injuries result from moderate and minor head injuries. Such injuries usually result from a non-penetrating blow to the head, and/or a violent shaking of the head. As luck would have it many individuals sustain such head injuries without any apparent consequences. However, for many others, such injuries result in lifelong disabling impairments.

A moderate traumatic brain injury occurs when:

  • A loss of consciousness lasts from a few minutes to a few hours
  • Confusion lasts from days to weeks
  • Physical, cognitive, and/or behavioral impairments last for months or are permanent.

Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits.

Severe Brain Injury

Severe head injuries usually result from crushing blows or penetrating wounds to the head. Such injuries crush, rip and shear delicate brain tissue. This is the most life threatening, and the most intractable type of brain injury.

Typically, heroic measures are required in treatment of such injuries. Frequently, severe head trauma results in an open head injury, one in which the skull has been crushed or seriously fractured. Treatment of open head injuries usually requires prolonged hospitalization and extensive rehabilitation. Typically, rehabilitation is incomplete and for most part there is no return to pre-injury status. Closed head injuries can also result in severe brain injury.

TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.

TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.1

Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.