The impact of brain injury on a person’s life can be vast, with the effects many. But what if an eating disorder comes into the equation? Solicitor Ewan Bain explores the issue.
The effects of an acquired brain injury (“ABI”) are truly multi-faceted, ranging from dysexecutive syndrome, neuro-behavioural issues, to more obvious physical disabilities.
It is well known that mental health issues and conditions can arise from acquired brain injuries; the well-known ones being depression and anxiety. However, what about Eating Disorders arising from ABI; is that possible and are they linked?
Whilst there have been massive strides in the neurological sciences over the past half century or so, there is still much more we do not understand fully.
Eating Disorders (which encompass conditions such as anorexia, bulimia, amongst others) are yet to be truly understood; it is still difficult amongst clinicians treating in this area what is often the best method to treat people with such disorders.
The clinical studies and clinical treatment of Eating Disorders is still evolving; so what does one do when presented with an individual who has an ABI and has thereafter developed an Eating Disorder?
The short answer is: it’s complicated.
Treating Eating Disorders per se is phenomenally tricky and if it is compounded with someone who has an ABI, which can bring with it other co-morbidities associated with that, it makes for a very convoluted clinical mix and a huge challenge for those clinicians trying to treat the individual affected.
What is an Eating Disorder?
An Eating Disorder is when an individual adopts an unhealthy attitude towards food. It does not necessarily mean eating too little, it can also involve eating too much, or being obsessive with one’s weight and body shape.
The goal of any intervention towards an Eating Disorder is to essentially:
- Restore physical health
- Develop normal patterns of eating habits/attitudes;
- Reduce the impact of illness and day to day functioning.
The goal is fairly obvious but achieving it is not. For a start there a number of differing disorders:
- Anorexia Nervosa – this condition involves where one tries to keep their weight as low as possible. They do this through not eating enough, excessive exercise or a combination of both.
- Bulimia – with this condition, people lose control and binge eat before then being deliberately sick or using laxatives.
- Binge Eating Disorder – losing control of your eating by consuming large portions of food at once which leads to feelings of guilt
- Other specified feeding or eating disorder (OSEED) – this is where a person does not have what classically fall under the above conditions but nonetheless have an issue.
The above conditions have differing approaches ranging from pharmacological to the psychological, or a combined approach of the two. The environment and setting of how such treatment is delivered can differ too and depends largely on the person’s wishes, the availability of specialist services and the clinical presentation of the person affected.
The impact of Eating Disorders should not be underestimated. As well as the personal impact on the individual and their families, it has wider social and economic connotations as well. PwC recently conducted research and prepared a report on the commission of the Eating Disorder charity, “BEAT”. That report estimated that the cost to UK society of Eating Disorders was circa £15 billion per annum, which is simply staggering.
Eating Disorders tend to affect the younger population and young females are the more prevalent group. One study found that there was mean incidence for anorexia, as an example, of 4 to every 100,000 in people aged 10-39 years.
What is more disturbing, using Anorexia again as a graphic illustration, is that Anorexia is often reported to have the highest mortality rate amongst all of the psychiatric disorders.
ABI with an Eating Disorder
It is uncommon to find individuals who have sustained an ABI, with no previous history or risk factor for Eating Disorders, to then develop one post-accident.
However, whilst it is uncommon, suffice to say, it does not mean it does not occur.
The clinical community are aware of the link between ABI and Eating Disorders but it is perhaps not as clearly agreed or understood amongst them is how best to tackle it.
There have been some reports and studies but it is understood that these are not vast by any stretch of the imagination. There is little data that exists which concentrates on food behaviour patterns with this cohort of people with eating disorders.
In one particular case study, the authors found that the cases “all had a frontal subcortical syndrome, expressed by neuropsychologic dysfunction, neuroimaging (frontal and basal ganglia lesions) and also as personality changes.”
They went on to discuss how patients with cognitive deficits might not be affected by behavioural strategies to combat their eating disorder.
They ultimately concluded the following: “the eating disorders in patients with traumatic brain injury may be present from early phases and persist years after the lesion….Eating disorders in the TBI patient should be approached and treated in a different way to a typical anorexia and bulimia taking into account the cognitive impairment caused by traumatic brain injury. Prospective studies are required to determine the importance of the different factors influencing eating behaviour of these patients. Results enable us to understand the course and progression of these disorders over time and establish appropriate medication for their control.”
What is evident from the above is that field of Eating Disorders faces its own battles in understanding and tackling the competing factors, be it clinically, socially or even politically (with respect to funding).
The added layer of an ABI into the mix, convolutes the picture further, what with insight and cognitive deficits.
This will be to some therapists and clinicians in the ABI field relatively new ground to them; therefore, it is difficult to say (even if one was from a clinical background) how to approach this.
What can be said though is that input is almost certainly required between specialist clinicians practising in treating patients/clients with atypical ABI symptoms and with those from the Eating Disorder field. It is therefore of the utmost importance that, for instance, a case manager presented with such a client, considers specialist input from psychiatrists and clinicians from the Eating Disorder field.
They will need to work in conjunction with those treating the typical symptoms arising from the ABI; the priority of treatment will undoubtedly be the Eating Disorder and without tackling that firstly, it may not lead to progress in tackling other areas such as the client’s cognitive deficits and associated behavioural issues.
Case Managers, therapists and even legal practitioners practising in the ABI field, need to act quickly if there is an inkling that their client could have an Eating Disorder.
Regular contact/communication with your client and their family should allow you to be alive to such situations.
If such a situation does occur, then the case manager/legal team should consider arranging urgent discussions with those concerned in the care of the client; individuals with Eating Disorders may not accept that they have a problem and added with possible insight issues arising from a ABI, then this needs a careful approach so as not to disengage the client.
- Ewan Bain, specialist brain injury solicitor at Switalskis Solicitors, was assisted by Dr Matthew Cahill, Consultant Psychiatrist, in preparing this piece.
High-res computer modelling to shed new light on TBI impact
Researchers have created a traumatic brain injury (TBI) computer model that maps blood vessels in a rat brain in the highest resolution yet.
The team at Imperial College London say the models could help improve understanding of how blood vessels are affected by TBI, as well as its effects on the protective layer encasing them known as the blood-brain barrier (BBB), which protects the brain from harmful circulating molecules and pathogens.
If the methods translate well onto human brains, Imperial say they could also help improve understanding of how TBIs develop and how best to treat and protect against them.
The simulations could even help to replace animal models of TBI, potentially reducing the use of animals in brain research.
TBIs are the most common cause of chronic disability in under 40-year-olds and result from severe blows or jolts to the head.
Beginning at the site of impact, mechanical forces travel in waves through the brain, twisting, stretching, and shearing brain structures as the injury cascades. These forces are known to affect blood vessels, but the finer details of the relationship between mechanical forces and vascular injury are yet to be established.
Now, researchers at Imperial have created a computer model of TBI which maps the network of vessels in the brain – called the vasculature – in the highest resolution yet, incorporating rat brain vessels just 10 microns in diameter.
Using the models, they found that adjacent blood vessels sustain profoundly different levels of stress depending on their alignment with neighbouring ones.
Blood vessels at 90 degree angles to others were less likely to be damaged, and vessels could be stretched to up to 14 per cent of their original length without injury, while stretching by more than this amount would result in injury.
Lead author Dr Siamak Khosroshahi, who conducted the work while at Imperial’s Dyson School of Design Engineering, says: “Our unique approach explains the unrecognised role of the vascular anatomy and shear stresses in how large forces cascade through the brain. This new understanding could contribute to improving TBI diagnosis and prevention.”
The degree to which the BBB lets molecules into the brain is known as permeability. The barrier can become more permeable after injury, making it more likely to let pro-inflammatory molecules reach the brain and usher in further injury.
By using rat models of TBI, the authors demonstrated that greater BBB permeability occurs in TBI as a result of disruption of the vasculature, and that this is most evident soon after injury.
From this information they created brain models digitally in high enough resolution to highlight the vasculature. They found that the computer models allowed them to accurately predict the distribution of stress in the small blood vessels of the rat brains. The models also allowed them to slow down time to look at the details of TBI more closely.
Senior author Dr Mazdak Ghajari, also of Imperial’s Dyson School of Design Engineering, says: “Injury happens in a fraction of a second, making it hard to observe exactly what goes on. By slowing down the process, we can pinpoint exactly which brain areas sustain the most damage and go some way to understanding why.”
The new, high resolution computer simulations could provide a blueprint for studying TBIs using more computers and fewer animal models, in line with the principles of Replacement, Reduction and Refinement (the 3Rs) in animal research.
The researchers say their models could also provide a more objective way to assess protection systems like helmets. Future studies on humans that include detailed reconstructions of the biomechanics of TBI are also needed to confirm the findings before using them to predict injury risk in humans.
The improved understanding of the BBB could also help further research into drug delivery of brain-specific medicines.
Head injuries in rugby players linked to brain structure changes
A study of 44 rugby players, almost half of which had sustained a mild head injury while playing has revealed a significant proportion had signs of abnormalities to the white matter.
A study of 44 rugby players, almost half of which had sustained a mild head injury while playing, has revealed a significant proportion had signs of white matter abnormalities.
It is the first study to assess long term changes in MRI images of professional rugby players. It also revealed abnormal changes in white matter volume over time.
The researchers say that more work is needed to determine the long term effects of rugby on player’s brain health.
The study took 44 players of which 21 were assessed after sustaining a mild head injury called a mild traumatic brain injury.
These are one of the most commonly reported match injuries accounting for one in five injuries. The rugby players were compared to other athletes in non-collusion sports and people who do not play sport.
Participants in the study underwent two MRI brain scans a year apart during 2017 and 2019.
The study used two advanced types of MRI called susceptibility weighted imaging and diffusion tensor imaging.
This reveals the structure of blood vessels and white matter. The white matter helps the brain cells to communicate with each other.
The players were also asked to complete memory tests to assess brain function.
Scientists analysed the brain scans for changes.
The scans revealed that 23 per cent of all the players showed abnormalities to their cell axons or small blood vessel tears. These tears cause small leaks in the brain called microbleeds.
The changes were seen in the players with and without a head injury.
Further research needed
Senior author from Imperial’s Department of Brain Science, Professor David Sharp said: “Despite relatively high rates of head injury and an increasing focus on prevention, there has been relatively little research investigating the long-term effects of rugby participation. More objective measures of the effects of sporting head injuries on the brain are needed to assist with the assessment and management of individual players.
“Our research using advanced magnetic resonance imaging suggests that professional rugby participation can be associated with structural changes in the brain that may be missed using conventional brain scans. What is not clear at this stage is the long-term clinical impact of these changes.
“Further research is needed to understand the long-term implications of repeated head injuries experienced during a rugby career and to provide more accurate ways to assess risk for an individual.”
The research was funded by the Drake Foundation. A not-for-profit organisation focused on understanding and improving the health and welfare of people impacted by head injuries.
It was supported by National Institute for Health Imperial Biomedical Research Centre, the UK Dementia Research Institute and the Rugby Football Union (RFU).
Dr Simon Kemp, medical services director at the RFU, added that a specialist clinical service for the assessment and management of retired elite players will be provided. It aims to assess the brain health of players.
“We welcome any research that helps to advance our knowledge which is why we actively collaborated with the academic institutions on the Drake Foundation Rugby Biomarker Study from its inception, particularly to promote the recruitment of players.
“While it is unclear from that research what the individual long-term implications are regarding the brain changes seen in these advanced imaging techniques, it is clearly a priority to investigate this further.”
Community rehab programme saved by brain injury charity
A vocational rehabilitation programme in the North East aimed at getting those living with a brain injury back into working life has been resurrected by a community charity.
Headway Tyneside worked closely with the NHS and fellow charities, Headway County Durham and Headway Darlington & District, to ensure the programme could continue following last year’s closure of Newcastle-based providers, Momentum Skills.
‘Headway to Work’ is the newly-branded service which will support around 14 people per year living in Durham and Darlington. Each participant will be individually assessed by therapists to gain an understanding of their difficulties, enabling the team to offer personalised support throughout the programme.
The training focuses on improving self-management skills such as self-care, goal setting, productivity, sleep and fatigue management, as well as technical skills such as IT and literacy. The final phase of the programme will involve voluntary placements for participants to ensure they feel comfortable, confident and have the relevant vocational skills before seeking paid employment.
In the future, the group hopes to deliver the ‘Headway to Work’ programme across more parts of the North East, within Gateshead, Newcastle, South and North Tyneside.
Alistair McDonald, chairman at Headway Tyneside, explains: “We all know how incredibly difficult the past 18 months have been. Those with disabilities or long-term health conditions have been especially vulnerable. The Momentum programme was well received and helped lots of individuals with a brain injury plan a route into employment, education or training and it’s fantastic that we can continue to deliver this type of service.
“The service will now be delivered closer to where participants live rather than having to travel to Tyneside. Less travel and being in a more familiar place should help people feel less fatigued and provide an opportunity to socialise and development friendships with other learners local to them.
“Currently, we have around 10 staff, including Julie Meighan our clinical service development manager, who will oversee training sessions run by a neuropsychologist and job coach. Julie worked as a specialist brain injury occupational therapist for many years so has the clinical knowledge and experience this programme needs.
“Our fantastic team of committed volunteers will support the delivery of this vital work to those who want to prepare for a return to work or plan a route into employment, training or education.”
Headway Tyneside is an independent charity providing support services to brain injury survivors and their families. In recent years, the board of trustees has developed a strategy to grow the scale and scope of services to provide more diverse and specialist services to their members.
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