They reported feeling self conscious about physical signs of their injuries. w3 Some of the symptoms the patients described at interview are often overlooked. Morris et al found that avoidance of social contact may be partly due to the injured person's inability to keep up with conversation as a result of slowed information processing, which in turn creates social anxiety. 2 Difficulties with social skills may arise from deficiencies in self monitoring and social judgment. Regardless of the age of the patient, it is the changes in cognition and behaviour that represent the greatest burden to families after a traumatic brain injury. The result is loss of self esteem, social isolation, and a considerable burden for families. Head injuries are most likely to occur in people aged 15-24 and as a result often disrupt important developmental processes, such as attaining independence from parental support, completing study and establishing a vocation, and forming social networks. w2 Twice as many had deteriorated as had improved (30% v 14%). Millar et al studied 418 patients, 85% of whom had had a severe head injury, on average 18 years after they had been assessed at six months after the injury. But other researchers found that a proportion of patients deteriorated when assessed 10-20 years later. w1 This might have been due to the expert and systematic care they received very soon after the injury. 1 New-combe found that veterans who had had a head injury in the second world war showed no evidence of deterioration many years after injury. Thus some long term studies, unfortunately often weakened by low rates of follow-up, show surprisingly good outcomes. In some patients further improvement is seen even as late as 5-10 years after injury. The vast majority of recovery after traumatic brain injury takes place in the two years after injury after this the brain injured patient faces an uncertain future. Problems with memory, attention, executive function, behavioural control, and regulation of mood, associated with injury to the frontal and temporal lobes, are particularly troublesome. Neuropsychiatric sequelae outstrip the neurophysical (such as ataxia or incontinence) as the major cause of disability. Traumatic brain injury is the leading cause of disability in people under 40, severely disabling 150-200 people per million annually.
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