The Role of Psychotherapy in a Neurological Institute
George P. Prigatano, PhD
Kris A. Smith, MD†
Division of Neurology, †Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
In a neurological institute, the study and treatment of diseases of the central nervous system are of primary importance. In many instances, however, treatment is only partially successful. A good neurological recovery often does not mean that patients’ higher brain functions are completely normal. Helping patients cope emotionally with such residual disturbances can greatly enhance patients’ quality of life—this is the role of psychotherapy in a neurological institute.
Key Words: brain damage, psychotherapy, quality of life
Brain injuries can produce profound changes in persons’ sense of reality and self-perceptions.[2,5,6] Memory impairments, language disorders, difficulties initiating action, and problems in planning and judgment are just a few of the neuropsychological disturbances that can shatter individuals’ sense of self-confidence and produce considerable despair as they attempt to live with the consequences of a brain disorder. Thus, helping patients to understand their neuropsychological deficits and to reconstruct their life in the face of (not despite) their personal suffering remains a central and vital activity of clinical neuropsychologists, particularly those working in a neurological setting.
The role of psychotherapy in postacute brain injury rehabilitation of patients with severe traumatic brain injuries is well documented.[3,7,9] The needs of patients with focal brain injuries for psychotherapeutic interventions vary. In a common scenario, patients undergo a successful neurosurgical procedure to treat a focal brain lesion and convince their neurosurgeon to release them to return to work. Many of these patients then encounter cognitive limitations that they did not anticipate and were not alerted to.[5,6]
The proper evaluation of higher cerebral dysfunction and, at times, the psychotherapeutic treatment of these individuals are important services for a neurological institute to offer. Expert neurosurgical and neurological care helps patients to avoid problems that threaten life itself. Once their life is preserved, however, patients may have residual neuropsychological deficits. Helping them to cope emotionally with such deficits is often crucial to their quality of life. The following case study, typical of patients encountered in a neurological center, is intended to alert neurological clinicians to issues that their patients often confront after medical and surgical treatment.
Figure 1. (A) Preoperative axial magnetic resonance (MR) image showing the cavernous malformation in the patient’s left temporal lobe. (B) MR image 4 months after surgery showing the resection bed and the surgical pathway through the cortex underlying the patient’s neuropsychological deficits.
In July 1998, a 55-year-old, right-handed, Caucasian male developed an episode of numbness in his right finger, then his right toe, and then his lips. He was examined at a local emergency room but was discharged home. Later he was seen on an outpatient basis by a neurologist who further elicited that his episode included difficulty with his speech and vision. A magnetic resonance (MR) imaging study of the brain revealed a cavernous malformation in the left temporal lobe about 6 cm posterior to the temporal tip (Fig. 1A). Hemosiderin surrounding the lesion appeared hypodense on T2- and proton density-weighted images. On T1-weighted images, a small central hyperintensity suggested a small amount of subacute hemorrhage. Before the one episode of hemianesthesia and speech difficulty, the patient reportedly had been asymptomatic throughout his life.
Based on the MR imaging findings and symptoms, the patient was evaluated by a neurosurgeon. He reported that his difficulties with speech had resolved but that he had ongoing problems with headache, generalized fatigue, and symptoms of depression. His medical history was positive for hernia repair, bladder infection, lower back pain, and umbilical hernia surgery. His social history revealed no major difficulties. He did not smoke and used alcohol sparingly. His family history was unremarkable except that his mother had experienced a cerebrovascular accident.
On examination, the patient’s Glasgow Coma Scale score was 15. His cranial nerve and extraocular muscle function were intact. His tongue protruded midline and his face was symmetrical. His pupils were equal, round, and reactive to light, and his visual fields were full to confrontation. His motor strength was 5/5 throughout, and his reflexes were slightly hyperreflexic on the right side (3/4) compared to the left (2/4). He had no pronator drift. Pinprick sensation was decreased in the right upper and lower extremities and in the distribution of the trigeminal nerve. He exhibited no dysmetria, and his gait was normal.
The patient was considered to have had an acute hemorrage from the cavernous malformation which manifested in a complex partial seizure and headaches. He was not considered an appropriate candidate for gamma knife radiosurgery due to the lack of evidence that gamma knife protects against hemorrhage from cavernous malformations. He was offered a treatment course of anticonvulsants and observation with serial MR imaging; however, he chose to undergo a transsulcal approach to remove the cavernous malformation (Fig. 1B). Surgery was recommended to eliminate the risk of future hemorrage and to prevent chronic epilepsy. After surgery, he developed a partial left upper quadrant hemianopsia. Postoperative evaluation of his mental status indicated no obvious higher-order disturbances involving language or memory. He may have experienced a brief simple partial seizure shortly after surgery; however, he has been seizure free and off medication for 2 years.