Hit on the head

How dangerous are concussions, can you control constant anger, and the lack of a "mind's eye."

Topics: Football, Peyton Manning,

I love football but worry about the effects of concussions, like the recent one suffered by 49ers quarterback Steve Young (who has had several). Are concussions dangerous or just bumps on the head?

A concussion is a blow to the head resulting in alteration or loss of consciousness. The key features are transient confusion, disorientation or other inappropriate behavior associated with amnesia for seconds to minutes to occasionally hours. Concussion is graded; alteration in behavior without loss of consciousness with full recovery within 15 minutes is the most mild (Grade 1). Any actual loss of consciousness (from seconds to minutes) is automatically Grade 3.

What actually happens to the brain is debated — some think it’s an electrical short-circuit in the brain stem and others think there is a microscopic tearing of axons (the long connecting arm of neurons) caused by shaking of the brain. There is no absolute answer to this.

In 1997 the American Academy of Neurology set out guidelines for the care of athletes experiencing concussion. After a brief Grade 3 concussion (seconds), a player must abstain from all contact sports until he is asymptomatic for one week. Following a second Grade 3 concussion, the athlete should be withheld from play for a minimum of one asymptomatic month.

A single concussion of this magnitude rarely, if ever, results in permanent brain damage. However, each additional concussion raises the odds of more serious sequelae (permanent effects). The effect is cumulative, especially if two injuries occur within a short time period.

I am no longer a football fan, having seen too many long-term injuries sustained in the pursuit of transient glory. I am unfamiliar with the details of Steve Young’s recent and prior head injuries; however my friends tell me that he has had several prior concussions. If so, he should not be allowed to continue. This is obviously a strong opinion, not based upon unequivocal proof or personal neurologic knowledge of his injuries. But more and more medical literature is pointing to the devastating long-term effects of repeated sports-incurred concussions.

Macho heroics are great. Ignorance of the consequences of such heroism isn’t.

I am infamous for having a short and volatile temper. I try to keep it under wraps, but it seems to leak out in minor explosions. I’m not so bad that I’ve physically hurt anyone, destroyed valuables or had outbursts at work, but I am often cranky and irritable and sometimes I just have to vent.



Is my anger a product of biology, environment or, as I suspect, both? My father had an awful temper and my family life was filled with constant fighting. But I’ve tried so hard to work through this, talk about it with my therapist and my partner, etc., and I still feel this sense of inner rage constantly roiling within me. I also have this sense of enormous guilt because I so desperately do not want to be like my father. Could there be something biological that is causing my anger? I have recently been diagnosed with sleep apnea (I’m going to have surgery this winter) — could this be the cause? Am I doomed to be a cantankerous demon the rest of my life?

Knowing whether a trait is primarily biological or acquired is both of great interest and presently of little value. In the end, the learned behavior of early childhood also becomes biological in the way that all patterns become neuronal circuitry. The question remains: Is there a way to change the circuits? “Clockwork Orange”? Cognitive therapy? Prison and jails? Skinner boxes (named for psychologist B.F. Skinner, who pioneered the concept of reprogramming behavior). I have even heard of therapists who videotape a patient’s session in the hope of embarrassing him into change. I’m sure the embarrassment is easy to come by, but the change?

There are two parts to anger, your response and whatever provokes it. If you’ve had great trouble controlling the rage, how about considering the most provocative circumstances, and considering what you can change in them. Or if you can’t change the circumstances, can you change the interpretation?

Yesterday I phoned 800 information to get the number for Sprint. The operator asked me where I was located. I said San Francisco. She said that she only had the telephone numbers for California and Texas.

I then phoned United Airlines and got put on endless hold. Steam was rising from my head. But the sales rep, when she came back from quilting, or whatever occurs on the other end of the hold button, was quite nice, and told me she was having a bad day. The last customer had phoned and asked if she was Alaska Airlines. When she said no, he asked, “Why not?”

And we laughed.

Human beings are not capable of perfection. We not only have faults, but we parade them like virtues. We are infinitely irritating when we take ourselves seriously. Much about life is serious, but we are seldom up to the task. We are not consistent, informed, mature, cooperative. We are irascible, contrary, impudent, unmanageable, filled with false notions and grand ridiculousness. And we are hilarious. Consider life a 6 billion-ring circus, a huge zoo filled with funny animals, a giant non sequitur, institutionalized madness. Stand back and enjoy.

The opposite of anger isn’t calm, it’s laughter. Anger means that you are taking yourself too seriously. I am all in favor of good psychotherapy, but be careful about believing in it. Therapy is also just another way of taking yourself seriously. Consider a paraphrase of Robert Frost’s epitaph: God, if you forgive me my minor transgressions, I will forgive you for the great big joke you played on me.

I have had a cognitive problem my entire life. Through years of reading, I have yet to find it listed anywhere. I have no conscious mind’s eye. I cannot close my eyes and visualize anything. I don’t recall or visualize phone numbers; yet I can dial them. I have to write down anything that I need to remember. Having stated that, I can recall what I was thinking about all the way back to an infant. I am now 59 years old. Are you aware of anybody else being like this?

One of the most dramatic recognition defects in neurology is prosopagnosia — the inability to recognize faces. The problem (lesion) is thought to be in the visual association areas of the occipital cortex — the region that converts raw visual images into the final perception. (The primary cortex sees lines, angles, edges; the finished picture is processed in the association areas.)

A brief example: a middle-aged man with primary degeneration of the visual association areas came into the consultation room with his wife, sat down next to her, across the table from me. He frequently deferred to her in presenting his history, turning to face her and ask her questions. I asked if he could point out his wife. He got up from his chair, walked around the room, inspected the wall hangings and my diplomas, then sat back down, turned to his wife and said, “She must be here somewhere.” I asked how he knew, and he answered, “Because I know I came in with her.” He then folded his hands in his lap and the two of us lapsed into the unbearable acknowledgment of his befuddlement.

I asked him how he came into the room. He got up and walked around, looking for the door. He found it, opened and closed it, then turned and said, “I can’t seem to find the door.” This was despite his vision being 20/20. He could see, but he could not recognize and describe.

Much of behavioral neurology is based on understanding various disconnection syndromes (one part of the cortex being disconnected from another): A man can read out loud, but he cannot understand what he has said, or he can write from dictation, but cannot read what he has written.

Such patients often have marked self-image problems, but there is no consistent pattern, as the resulting behavioral disturbances are quite dependent upon the prior personality. This is the crossroads between neurology, biological psychiatry and pure metaphysics. Can you imagine how you would feel about yourself if you spent your entire day with a woman that you could not recognize as your wife. (Yes, perhaps with the exception of sex.) Alienation is at the heart of terror; it is no wonder that we neurologists tend not to emphasize such behavioral consequences.

A young man (an accountant) underwent cardiac surgery, sustained a complication — a cerebral embolism that destroyed much of his occipital cortex, but left him with residual pinpoint (tunnel) vision. He could see a small percentage of his former visual field, but could not keep his entire visual environment in mind despite continuously scanning it. All he could describe was what was directly in front of him. A neurologic example of “out of sight, out of mind.”

The most fascinating behavioral change? The man became profoundly paranoid. Because he could not envision the space around him, except by turning to look at it, he had no idea where he was in relationship to a door, window or passing traffic. Because he could not know what was behind him, he imagined all sorts of possibilities, including the most bizarre and threatening. He began to hug walls, his back pressed against an edge of his personal landscape. He used his back as a tactile defense against his fears, limiting himself to slinking around rooms.

He became a tragic ongoing experiment in sensory isolation. His mind’s eye had failed him.

You say you’ve had your problem all your life. In all likelihood, this represents an isolated developmental disorder. I suspect that you are at one end of the spectrum of mind’s-eye ability, the other being Michael Jordan, who can re-create an entire basketball court, or a master chess player who can play multiple games, keeping all the games in “mind.”

Recommended reading: Oliver Sacks’ book “The Man Who Mistook His Wife For a Hat.”

Robert Burton, M.D., is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not." His column, "Mind Reader," appears regularly in Salon.

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