Understanding Cognitive Impairment

  • Introduction
  • Causes
  • Mind and Brain
  • Repetition Builds New Pathways
  • Cognitive Intelligence
  • Metacognition
  • Perception

Introduction

Impairments in executive functioning have been linked to dysfunction of the frontal lobes.

The way we think can change following a brain injury because of the disruptions within the neurological networks. 

If we think of input as anything coming to us via the senses, then we can understand that we need the brain to make the connections for this information to have meaning.

Before the injury, your brain would utilise all established information and preferences and find the input familiar or unfamiliar. Unfamiliar information is treated with suspicion until we have assessed the context.

How we each assess unfamiliar information depends on:

  • our potential, i.e. personal tendencies and preferences
  • our understanding of these and our ability to find out more information
  • our ability to compare this again to our potential,
  • decide if we need more information
  • and to repeat until we reach a conclusion or realisation

The physical damage to the brain disrupts the neural circuits we depend on to do this, I.e. tearing and shearing, and the way electrical impulses travel through the brain.

Neurotransmitters drive these electrical impulses, and these too can be disrupted by trauma. In effect, it is like trying to move from A to point B 5,000 miles away with a blindfold on and no map.

To function well, i.e. predictably and in familiar ways we recognise, we need all areas of the brain to be able to communicate with each other.

The frontal lobes are a key area for turning the impetus into realisation. When there is damage here, our ability to assess all input and to consciously create managed and controlled output is affected.

A brain injury may mean that you are unaware of impairments and also oblivious to what came out – the output.

This lack of insight or inability to self-feedback is also caused by loss of functionality within the frontal lobes—the links we need and should be making become disparate.

Dysexecutive Syndrome (DES) is considered in three broad categories – cognitive, behavioural and emotional.

The signs of behavioural and emotional outcomes often overlap in most peoples’ observations, but the indications of cognitive issues are generally easier to spot. However, it can be difficult for people to understand what is causing a particular behaviour or action because often, many things are happening all at once.

For example, being glued to the sofa could be apathy, problems with knowing where to start, flooding, depression, difficulty breaking things down, and so on. It could also be all of these things happening together. The best thing to do, as an observer, is to resist making any judgements because often these are based on what we would typically assume about the everyday world, rather than being based in clear and objective understanding about brain injury.

Getting it wrong can inadvertently lead to an awful lot of upset, as many of you may well have found out.

By learning more about the outcomes, and what causes them, we can all start to be better objective observers, and those who are learning all over again can become more self-objective

Causes

Cognitive disruption is mainly caused by the ‘physical’ neurological damage such as tearing, shearing, and any resulting cell death. 

However, secondary outcomes also contribute to this insult. Treatments and best management of the biochemical cascade or secondary brain injury, are still being investigated. 

You should speak to your doctor about when to address the inflammatory response because there are beneficial effects which prepare the brain for neuroplasticity and repair. 

The main thing is that regardless of the initial cause, the executive functions are significant contributors to ‘familiar thinking’ and feeling a recognisable inner sense of self.

The ‘how’ of how we individually think has a huge part to play in how we feel about ourselves and our ability to maintain our unique integrity following trauma. Based on many things, this sense of self includes our history, upbringing, beliefs, habits, and experiential memories. Brain injury can disrupt all of these aspects.

People must feel understood and supported, and often, especially where there is a lack of medical treatment and understanding, family and friends find that they take on the role of caregiver. ‘Helping’ can be a mammoth and seemingly impossible task – but it is never fruitless – even when you are getting it all wrong – all feedback and communication help the rewiring process.

All interaction is helping because it is all giving the injured brain a chance to learn. Understanding more can help with the stress levels, and when reduced, so is cortisol output. Please see the dangers of stress and cortisol.

Mind and brain

The brain is a ‘tool’ used by the mind. The brain isn’t ‘who we are.’

The mind can conjure all kinds of flexible thought that the brain could never even imagine – let alone do. It is by understanding that the brain is a ‘broken tool’ that the mind can start to fathom how to fix it. Think of the mind as the observer and overseer. Without understanding this, ‘healing’ and rehabilitation is drastically slowed.

We have to be able to sort the wheat from the chaff and know who the boss is. The ‘mind’ is definitely in charge and is useful in directing the broken brain. When we can’t ‘hear’ our thinking voice or inner narrator it is much harder to be the captain of your ship. 

If this seems confusing, one thing that many people are familiar with is how we can all struggle to think when we feel overwhelmed – it can feel as though all our faculties have deserted us.

Depressed moods are another good example because people very often feel as though they can’t ‘choose’ their thoughts. It is this ability to be in control and to make choices about our ideas, that gives us a real sense of feeling that we are more than just our brain.

That science now understands that we are indeed much more than the physical brain organ, supports the descriptions people give of their struggles with brain injury.

Many people report losing awareness of the ‘thinking voice’ in their head, and this is frightening, upsetting and confusing.

You can work out whether you can still ‘hear’ your inner narrator by running a quick test on yourself. Look over to one wall of the room you are in and, in your head, describe it to yourself. If you can ‘hear’ what you are saying, then this is your ‘mind.’ It is the inner voice that many people ‘forget’ to hear after brain injury. Practising this simple exercise in times when it feels as though we can’t interrupt ‘streaming’ and incessant thoughts, can help remind us that we do have the power to choose and also the capability to redirect.

If this exercise was quite strenuous for you, there are things you can do to help this such as, journaling, reflective techniques and mindful breathing exercises. ‘Black seed oil‘ also helps by improving the brain environment.

When you get the gist of using your ‘thinking voice’ you can then use this ‘boss’ to start fixing your brain. Without this realisation, we can easily be stuck never realising there is something we can do.

It isn’t always the emotional overload that keeps people perplexed – sometimes it is caused by not knowing what is going on.

Keep practising with the techniques. They are all part of rewiring the physically broken pieces of your brain. Repetition builds new pathways.

Repetition builds new pathways

This is an excellent picture of the myelin sheath because it shows the ‘growth rings’ – just like a tree has.

There is so much information about the myelin sheath, and repairing and rebuilding it, that it gets its’ own page!

Damage to this sheath is the thing that causes problems with memory, cognitive function, and also movement, to name just a few. The primary damage caused by brain injury means we often have to start from scratch with a lot of our learning and skills.

Forming new ‘networks’ is entirely dependant on repetition. There is a lot we can do to help this process, and ourselves, and it is very well worth the ‘deeper’ look.

The secondary injury also damages the myelin sheath, as can diet and toxins in our environment. Addressing the health of the brain environment is imperative. We must do everything we can to support all brain function and make sure we don’t do any further damage to it. Black seed oil has been shown to benefit the repair of the myelin sheath.

Cognitive Intelligence

In general, many people interpret their intelligence based on how ‘easily’ they can problem-solve. Cognitive impairment doesn’t directly affect innate intelligence – instead, it affects the way this intelligence can work.

The way we are able to think changes after a brain injury. For example, information comes to us from both our external and internal environments.

We pick up information through our senses, proprioception (awareness of our physical orientation and movement), and through our emotions and feelings.

Processing this information is usually slowed in people following a brain injury, and as we try and transform what we know or sense into perception, or understanding of the details we need, we might notice a lot of information is missing or doesn’t get through, or, alternatively, everything comes in unfiltered and we feel totally swamped and overwhelmed all the time. 

Matching this data

Matching this ‘incoming’ data can also be problematic and extremely challenging – especially when you struggle with loss of self-awareness and loss of insight.

To really understand where you are in time and space you need to know, or need to be able to match, your past history, your expectations, your values and beliefs to what comes in so that the view you have of your world, moment-by-moment, feels like it is ‘you.’ 

Your personal preferences and experiential memories have an active influence on what you are perceiving, and usually, this all happens so fast that you trust it, and you trust your responses. 

A brain injury can mean that you will ‘feel’ as though this has happened, and therefore, you will believe that your response can be trusted in the same way you have always felt. 

What we don’t see

Because cognition includes all the mental processes that allow you to behave in familiar and recognisable ways, it feels, from the ‘inside,’ as though all of this is still happening. 

We need everything to match up in order to be able to function and to output meaningful actions, communications, responses, and behaviours.

What we don’t see is that the ‘matching’ isn’t happening the way it used to because of memory and data losses. Information isn’t relayed through the brain in the same ways and what comes out isn’t what we expected. This is what other people notice, but because the brain isn’t able to feed this back to us – we don’t see it at all. 

We can have little or no awareness that anything has gone awry.

It isn’t your intelligence or who you are that has changed; how your brain is able to function is the the change that makes the difference. 

Just because you no longer have intellectual access to your values, beliefs, and personal history, doesn’t mean it isn’t there – it means your brain can’t find the access to it at the time it is needed. 

Cognitive impairments include outcomes such as difficulties or inability to plan and organise. It doesn’t matter how much you may ‘want’ to do these things – if you have a brain injury, the fact is, you can’t, or will struggle. The map ‘to it’ has been erased or damaged. Sometimes you have to start again; sometimes there is a lot of work to do to improve function.

The intricacies of rewiring will depend on the damage that has happened uniquely in your brain. The power of nature is on your side, and there is an awful lot you can do to help it.

Metacognition

It is probably advantageous to describe metacognition in a working brain so that we can more easily compare this to what happens in someone with a brain injury.

Some people retain metacognition and are more easily able to describe their difficulties and impairments – they preserve self-awareness, but have other functional problems.

Metacognition is really ‘higher consciousness.’ It perceives your thoughts and what you are doing with tremendous speed, and is able to accurately feed back and monitor what you are up to based on your held perceptions about you and your life. It knows what you believe, what your values are, and if something doesn’t ‘match,’ this higher consciousness will let you know. 

For example, your personality may be fully committed about achieving a specific goal, and, if you are tired or having a bad day your thinking voice will tell you to have an early night and to tackle your project again tomorrow. 

This higher consciousness knows everything about you and, if you use it wisely, can be the best friend you have because it helps you balance who you are and to make choices based on everything that is a part of you such as, values, moral behaviour, conscience/your personal sense of what is right and wrong for you, your beliefs, everything you have experienced and what you made of it at the time, what you added in hindsight, and so on. 

Our metacognition lets us be aware of what we know about our capacities, abilities, challenges, limits, likes and dislikes, and our cognitive processes. We are entirely familiar with how our brain works, and with how we ‘talk’ to ourselves. 

Executive functioning and metacognition

Our executive functions operate on this metaknowledge or wisdom. By working together these brain processes give us a sense of who we are. 

Also, when in unison, these functions verify everything we are doing and saying, as we are doing and saying anything. This is our ‘observer’ who is monitoring everything the brain is doing so that we feel a sense of purpose and control. We have directionality because we are fully aware of previous choices which are driving what we are doing, and we are also conscious of why.

When we are performing a simple activity the brain is able to achieve the desired result through habit or automatically – the point of unconscious competence.

When something doesn’t match, then the executive functions kick in, and we start higher level thinking such as problem solving. This operation will take into account what we may previously have planned, update or change to make this still viable or achievable, and also anything we do by routine, and then will output an action that is entirely in keeping with our characteristics and norms. 

This amazing working brain is soaking up everything we need, reflecting on it faster than we can think, and making sure it matches with our values and beliefs so that ‘what comes out’ is both predictable and familiar.

When this isn’t working

Probably the most significant difference between a working brain and one that is injured, is no longer knowing what you know as you are trying to do something. 

You don’t know – that you don’t know.

It is as though the metacognitive abilities are switched off.

You can’t hear yourself think, you can’t monitor what you are doing, and you are like a cave fish floundering in the open ocean. 

Without metacognition, your beliefs, values, and aim aren’t matched up, and the executive functioning doesn’t kick in. 

Confabulation

Confabulation is a common and problematic outcome that happens when metacognition and executive functioning can no longer monitor what we are saying. 

Based in memory impairment and often experienced as ‘gap filling’ by people living with brain injury, confabulation is when you are trying to say something sensible but what comes out is untrue to any observer. 

When information of any kind is missing, the brain wants to present well, so that we can retain relationships, social circles and fit in, and it is this ‘pressure’ that results in the brain finding a nearest match to slot in where the real information can’t be found. 

This can be particularly problematic when someone has difficulty learning and relating autobiographical information after a brain injury. For example, it might feel as though memories are no longer linear or linked up. 

Think of each detail of a memory as a glass marble, then picture all the marbles about a topic being put on a metal tray and rocked around, and what comes out is as much of a mess as the marbles now are. 

The motivations and intentions are the same – the brain can’t match this to desired output because the systems are broken.

Working memory isn’t working so what goes in from the internal and external environments isn’t always filed, and when it is, it is filed incorrectly because not all the details were captured. 

These experiences make people feel as though they can’t trust themselves, and when you don’t have confidence in yourself it is difficult to protect or stand up for yourself and keep faith in others. 

The broken brain is unable to run the verification and comparative processes it once did. It isn’t the person who has changed, it is the brain which is no longer functioning the same way that outputs unexpected content. 

The person will be putting in tremendous effort, which is often totally unrecognised. 

Lack of Realisation

When you live with these kinds of disabilities there is often no realisation that things are going as badly as they are. 

None of the normal processes are working in the same way, so you get very different results. People on the ‘outside’ can see this but often find it difficult to understand and people on the ‘inside’ are oblivious. 

Perception

When cognitive tools are broken, the mental process that allow and help us achieve wanted, desired and meaningful actions and behaviours don’t work.

Perception is a functional tool and allows us, when it is working, to know what our immediate experience or understanding of our world is. We know what is coming in from outside of us, and also what we are thinking and feeling from the inside. 

For example, say you are standing outside in the cold and rain, and someone says that you are lying. Your emotional reactions rise, you are aware of them, you are aware of your discomfort, the body language, facial expressions, and tone of voice of the other person, all in the blink of an eye. Your brain sums everything up and ignores the passing car, which was irrelevant to the conversation. 

If you have a brain injury you miss all these cues; you feel swamped because your brain is trying to work out what the passing car had to do with the situation, and overwhelmed with confusion because, to you, what you said was the truth.

Perception allows us to make sense of the senses.

If you don’t have access to stored knowledge, everything that is ‘incoming’ is being treated as if it were entirely new to you. This creates feelings of being completely overwhelmed and as soon as you realise this, you also realise that you can’t remember any details of what just happened because your short-term memory isn’t working. 

In every moment of every day it feels as though your brain no longer has the capacity to handle ‘complex’ situations. It can feel as though your brain previously had the capacity of a large car sponge to soak up incoming information, and now this sponge is the size of the moon on your little fingernail. 

Without experiential memory, you can’t use concepts from past knowledge to help you break things down. 

Loss of access to knowledge and historical information can also mean that where you would usually be able to use this to recognise the influence this has on you, you can no longer truly understand the context. Factors that would usually affect context and your ability to perceive things in multiple or flexible ways also breaks down.

When you fail to get the context ‘right’ from your perception, this adds to the challenges you have with adapting behaviour in order to respond appropriately. 

It is the mechanics of the brain that are broken – not the person who has changed. 

When families and friends compare inappropriate response or behaviour to their own spontaneous, lightening-fast, and automatic perceptions, they inadvertently misjudge the individual with the broken brain. 

Disordered perception is extremely difficult to understand. The important thing to remember and know is that these systems won’t be working one minute, and not the next. The fail until the individual starts to rehabilitate and recognise their impairments.