When a patient first comes out of coma, especially a prolonged
comatose patient, the type of responses that you may see will
still be minimal but as progress continues you will notice that
certain emotional responses will become more prevalent.
DEPRESSION
One of the most common responses is depression and usually manifestation
of depression does not occur right away. A patient who is depressed
shows depression by withdrawing or doing less than previously.
That is not always a negative sign. WHY? Because it shows that
intellectually and cognitively the patient is making progress
enough to recognize that there is a reason to be depressed and
that is a very good sign. Another reason for depression is because
they are frequently if not constantly comparing their present
condition to the way it used to be. This also shows a cognitive
progress allowing for that kind of understanding. Families may
like to show them pictures of themselves and mean well in doing
so but it certainly is a clear cut reminder of the fact that
the patient is not functioning now as the way he used to. Depression,
although it is positive in that it shows intellectual progress,
certainly can interfere with ongoing progress in a rehabilitative
program. A patient who is depressed tends to be less interested
in doing much of anything and certainly not interested in rehabilitative
efforts. If you think about most things that are done in the
early stages of rehabilitation--they are boring. They are not
the kind of things that most people want to do and a person
who is depressed will have even less of an incentive to do so.
ANGER
Anger can be in existence for a number of reasons. Patients
can be angry about what caused the coma although for the most
part they don't really recall that much about it. However they
have heard about it in many cases through family and friends.
Even if they don't know exactly what caused coma, they are angry
about the fact that they were in a coma with all the changes
that it has caused in their lives. They are angry about the
lack of progress they are making and in many cases family members
will see progress but the patient will not, especially if progress
is slow. Patients will express this anger frequently, intensely,
a lot of temper tantrums, lots of yelling and screaming. Again
anger as an emotional reaction is not always negative as it
is showing progress is taking place. Ask anyone whose loved
one is still in coma and they would be thrilled if their loved
one would show anger as anger is a sign of progress.
LOW SELF ESTEEM
Very frequently patients who are recovered to the point where
they can start communicating verbally will indicate that they
believe they are inferior human beings. A number of patients
refer to themselves as retarded cripples. We know for a fact
that doesn't exist because for the most part those that call
themselves retarded cripples are intelligent enough not to be.
They see themselves as being inferior to their peers, in fact
inferior to just about anybody and this can be a contributing
factor to depression or withdrawal as well.
DENIAL
The recovery patient who denies there is a problem says, "I'm
fine. I don't have a problem, I don't need anymore therapy,"
when it is obvious to everyone else around him that that's not
the case. It's important to you to be aware of what the patient
is going through so you can provide the best possible support
for that patient. Obviously, there are other common emotional
reactions such as the reaction of anxiety, or regression to
childlike behavior. Emotion is a very important part to any
recovery process as emotions play an important part in our behavior.
WHAT ARE THE DIFFERENT ASPECTS OF PATIENT FUNCTIONING
THAT NEED RETRAINING AFTER COMA AROUSAL?
They are physical retraining, medical stabilization, speech
and communication improvement. These are all very important
parts of the rehabilitation process. There are also behavioral
aspects dealing with the way the patient is functioning and
the cognitive aspects of the way the patient's mind is working.
From the behavioral aspects point of view, one of the first
things that takes place in retraining is basic functioning.
Retraining one to feed himself, eat, dress-taking care of the
basic needs. This of course is very elementary but for some
patients who are making slow progress, the need is exorbitant
and it takes a long time to teach even some of the most basic
skills and this is when a patient is willing to cooperate.
The other important aspect of behavioral function is social
functioning, getting along with other people. This brings up
one of the most important changes that takes place in a lot
of patients following arousal from coma. It is called loss of
impulse control. Think about children, as they grow they become
less and less spontaneous in things they do. The reason is as
we raise our children we try to teach then the difference between
right and wrong and as they grow they learn the difference between
appropriate and inappropriate behavior. It's almost like there
is a little switch in their brain which previously was in the
"on" position controlling their impulses and has now
malfunctioned and they are no longer able to control their impulses.
You may see major changes in personality and behavior in patients
following head injury. Patients who before were nice, sweet
gentle people prior to the onset of coma now become monstrous.
You don't recognize this person-he has changed so much. It doesn't
occur in all cases but when it does occur it is frightening.
There are three basic ways that the patient will show loss
of impulse control.
1-Physical violence
2-Sexual aggressiveness
3-Verbal aggressiveness
Physical violence can be used against anyone or any thing.
Maybe the patient is lashing out because of the frustration
in himself or maybe this is the only way he can express himself
or because he cannot control himself. Patients do not seem to
recognize that what they are doing is wrong.
Sexual aggressiveness does not just have to be physical. There
can be a lot more suggestive and verbal content and overt sexuality
on their part such as exhibitionism or public masturbation.
Verbal abusiveness can really be profane. Words that you didn't
think the patient knew pour out and can be embarrassing to all.
The most prominent question dealing with the loss of impulse
control is: "Can it be retrained?". Yes. A combination
of time and implementation of certain behavioral modification
techniques can effectively retrain this loss. In over months
and years the progress toward regaining this loss is steady
and in some cases some recover more quickly than others.
The other aspect of functioning that is important for retraining
is the cognitive aspect. How is the patient's mind working?
This aspect can contribute to a lot of the emotional or behavior
problems mentioned above. Memory is the major cognitive problem
faced by the recovering patient and the most common problem
experienced by patients. The memory problem that exists tends
to be the short term memory.
1. Immediate recall-if asked to repeat a word just spoken
to you and you repeat it.
2. Short term memory-if asked tomorrow to repeat the word.
3. Long term memory-if next year you are asked to repeat the
word.
Not all cases but in most, patients have little difficulty
in immediate recall. If asked to repeat a sequence of two or
three numbers, they can usually do it quite well. Long term
memory is also not much of a problem. Patients will remember
childhood friends, teachers, hobbies, etc. Most of the retraining
is for the short term memory. Patients have a lot of emotional
and social problems because of their memory problems. They may
have difficulty carrying on a conversation because by the time
they get to the end of the sentence they have forgotten what
they have said in the beginning or they may not remember who
they are talking to. If they pick up the phone to dial a number,
they may be able to remember the number but not whose number
it is. They can have emotional problems because they can't remember
what they did this morning or yesterday or even five minutes
ago. They feel like they are living in a twilight zone. They
are living for the minute literally and they don't have recall
for what happened!
All the patient can go by is what others tell them they have
experienced and this can be very frightening. Short-term memory
problems are one of the biggest problems the patient has to
face. The key to helping them is repetition. You must tell them
everything over and over and over again.
In addition to memory, concentration is a problem to recovery
patients. Attention span is very, very short which makes any
therapy incredibly difficult. A patient with small attention
span is easily distracted and they tire very easily. Patients
recovering from a coma show a high rate of learning disability.
The learning disabilities are not necessarily the same as children
who are diagnosed as being learning disabled. This simply refers
to the fact that they may have more difficulty remembering material
that they are being taught because of the memory problem. Also
a recovering patient may show difficulty with abstract thinking
and reasoning skills. They tend to be more concrete in their
thinking. In many cases they tend to be less likely to understand
jokes that are abstract, where as the more physical slap-stick
kind of comedy they can readily perceive and understand and
laugh at.
return to COMA CARE
