Changes Following a Traumatic Brain Injury Does a person become their disease?

By Jasmine Ali-Gami

Thirteen pounds, one metre, and a diameter of 3.2 centimetres. 1

These were the metrics of the bar that was blasted into twenty-fiveyear-old Phineas Gage’s skull. Gage was employed in a railroad construction business in Vermont, USA, in 1848. The construction group was responsible for blasting a rock, of which Gage was assigned the task of putting gunpowder into a hole. Unfortunately, there was a miscalculation in trajectory and the bar entered Gage’s skull through his left cheek and destroyed his left eyeball before making its way into his frontal lobe. What remains so astonishing, is that Gage survived. In fact, he remained conscious and verbal the whole way to his doctor’s office. 3 Gage’s treatment included the removal of his left eye and the bar being surgically extracted from his brain, leaving the frontal bone of his skull fractured. He was released from the hospital only three weeks after.

Before his accident, Gage was a competent employee, with a strong sense of leadership, and known to have a gentle personality. 1 But do you think that changed post-accident? Would the projection of the metal bar into his frontal lobe ultimately lead to a demise in his notable personality?

“Is it neurological, or is it psychological?”

This is an age-old question set to differentiate disorders, behaviour, and personality traits from one field of study to the other. Some academics before the 20th century believed both fields to be mutually exclusive; meaning neither field is influential on the other.2 Changes in psychology were presumed to be solely the result of external factors like diet, environment, or even evolution. The idea of a “mind-brain” dichotomy was rejected based on the belief that psychiatric diseases exist without any corresponding brain pathology. This sounds hard to grasp given neuropsychology’s recognition today. But in the past, without proof of an association, scientists didn’t buy it. And we can’t blame them for that, because science is only science with well-supported evidence. However, with the case of Phineas Gage, it became clear that the brain and mind are connected. Gage remains one of the most famous patients in the history of neuropsychology and neuroscience 3 Many undergraduate students can attest to that—he is one of the hallmark cases introduced in Psychology 101 courses.

Gage’s physician, Dr. John Harlow, determined the accident profoundly changed Gage’s personality. 1 The once gentle and reliable foreman was now irritable, unreliable, rude, and hostile.4 He ultimately lost his job due to his consistent use of profanity and hostility toward coworkers. Gage couldn’t hold a steady job and his life changed, his temper shortened, and his relationships ran sour to the point of his family and friends saying he was “no longer Gage.”

Thus, Gage’s changes post-accident can be understood from both a neurological and psychological perspective.4 He suffered a severe traumatic brain injury to his frontal cortex, leaving irreversible damage, and also suffered from long-term psychological damage exemplified by his drastic change in personality.

Another key element in Gage’s case is that it disproved the mainstream understanding of the function of the frontal cortex1. The frontal cortex was known to be a “silent structure,” having little involvement with a person. However, it became clear that the frontal cortex was far from silent, but rather responsible for mood, personality, self-awareness, and moral reasoning, all of which were severely impacted by the injury to Gage’s brain5

Traumatic Brain Injuries

A Traumatic Brain Injury (TBI) is defined as damage to the brain upon an external force.6 The diagnosis of a suspected TBI includes one or more of the following clinical signs immediately after the event:

1. Loss or decreased level of consciousness

2. Loss of memory of event

3. Alterations in mental state

4. Neurological deficits (i.e., loss of balance, change in vision, balance etc.)

Does a person become their disease?

There is ample evidence of the association between personality changes after a TBI, and the pure abundance of cases can be daunting for people who have loved ones who’ve suffered from a recent TBI. So, I’d say no. A person does not become their disease, nor should they be reduced to their trauma. Yes, the impact on the brain can be devastatingly detrimental to one’s well-being and psyche, but the level of plasticity in our brain can be repaired and changes are possible.7 Even in the case Phineas Gage, studies reported the personality changes stayed for four years. Afterwards, he improved and was able to hold onto a steady job. Gage’s story was a landmark case for neuropsychology. I think his improvement post-accident can be just as important to learn for those who have suffered from a TBI. After a severe injury to the brain, normalcy is possible and improvements can be made.

References

1. Teles Filho RV. Phineas Gage’s great legacy. Dementia & Neuropsychologia. 2020 Dec 11;14:419-21

2. Price BH, Adams RD, Coyle JT. Neurology and psychiatry: closing the great divide. Neurology. 2000 Jan 11;54(1):8-

3. Schleim S. Neuroscience Education Begins With Good Science: Communication About Phineas Gage (1823–1860), One of Neurology’s Most-Famous Patients, in Scientific Articles. Frontiers in Human Neuroscience. 2022;16.

4. Oni MB, Wilde EA, Bigler ED, McCauley SR, Wu TC, Yallampalli R, Chu Z, Li X, Hunter JV, Vasquez AC, Levin HS. Diffusion tensor imaging analysis of frontal lobes in pediatric traumatic brain injury. Journal of child neurology. 2010 Aug;25(8):976-84.

5. Mckee AC, Daneshvar DH. The neuropathology of traumatic brain injury. Handbook of clinical neurology. 2015 Jan 1;127:45-66.

6. Blennow K, Brody DL, Kochanek PM, Levin H, McKee A, Ribbers GM, Yaffe K, Zetterberg H. Traumatic brain injuries. Nature reviews Disease primers. 2016 Nov 17;2(1):1-9.

7. Bherer L. Cognitive plasticity in older adults: effects of cognitive training and physical exercise. Annals of the New York Academy of Sciences. 2015 Mar;1337(1):1-6.